It’s time to ‘Build Back Fairer’: what can we do to reduce health inequalities in cardiology?

Disparities in cardiovascular morbidity and mortality are among the leading health and social care concerns in the UK. The disruption of the COVID-19 pandemic to health services has further placed cardiovascular care and the respective patient communities at the sharp end, not least in exacerbating existing health inequalities across service interfaces and patients’ health outcomes. While the pandemic engenders unprecedented constraints within established cardiology services, it conduces to a unique opportunity to embrace novel transformative approaches within the way we deliver patient care in maintaining best practices during and beyond the crisis. As the first step in navigating toward the ‘new norm’, a clear recognition of the challenges inherent in cardiovascular health inequalities is critical, primarily in preventing the widening of extant inequalities as cardiology workforces continue to build back fairer. We may consider the challenges through the lens of health services’ diverse facets, including the aspects of universality, interconnectivity, adaptability, sustainability, and preventability. This article explores the pertinent challenges and provides a focused narration concerning potential measures to foster equitable and resilient cardiology services that are patient centred in the post-pandemic landscape.

Introduction

Disparities in cardiovascular (CV) morbidity and mortality are among the major health and social care concerns in our modern society. In the UK, people living in the most deprived areas are four times more likely to die prematurely from CV disease (CVD) than those living in the least deprived areas.¹ To address the disparities in CV outcomes, it is imperative to recognise the presence of inequalities at different interfaces of cardiology services. This article, therefore, aims to provide a focused discussion concerning potential measures to reduce health inequalities in cardiology through the lens of the challenges: “Universality, interconnectivity, adaptability, sustainability, and preventability.”

Universality

Despite universal healthcare services and standardised treatment guidelines in the UK, the morbidity and mortality outcomes across different ethnic populations during the pandemic demonstrated that all is not equal with regard to universality and clinical outcomes. Recently, an article in Lancet Public Health investigated the England-wide general practice patient survey, which reported substantial ethnic inequalities in health-related quality of life among older adults, particularly in women. Further, there was a greater likelihood in patients from ethnic minority populations to report a poorer experience than their white British counterparts in using health services.² Such observation portrays that universal access to healthcare services may not necessarily lead to the same clinical outcomes in all patient groups. This leads us to consider the concept of proportionate universalism (delivering universal services while providing targeted support for vulnerable groups) as a model of care to address health inequalities.

Given the complex interplay between coronavirus severity, CVD and the broader determinants of health, there has never been a better time in exploring novel care delivery in cardiology that capitalises on the concept described above as we emerge from the pandemic. In the multi-ethnic British population, cardiology services need to culturally tailor local facilities to reduce health inequities across communities that are disproportionately affected by the CVD burden. Linguistic barriers can often be an impediment to patients’ understanding of disease-related information and treatment adherence as a result, especially when some cardiology terminologies can be technical and confusing for patients with limited English proficiency.³ This can be compounded by systems-level barriers, including, but not limited to, short allocated clinic time for such patients. To ensure equitable cardiology care, we need to optimise language concordance between physician and patient, ease of access to professional interpreting facilities and availability of translated documents, such as patient information sheets and culturally adapted healthy living handbooks. Some of the systems-level barriers can be anticipated and reduced by implementing proactive screening for such cohorts in advance of clinic allocation. In addition, several studies have attested to the positive impact of workforce diversity on the inclusiveness in population health management.^4,5 As such, we need to foster a diverse and inclusive cardiology workforce in pursuit of equitable healthcare for the under-served.

Interconnectivity

Interconnectivity in healthcare empowers a culture of shared decision-making via the accessible and actionable clinical information exchange between the public, public health, health services, voluntary sector partners and local authorities. The unprecedented pandemic has showcased the potential of trans-sectoral collaborative ventures in addressing health inequalities in a short period. To take on health inequalities in CV care, strategic partnerships with local and voluntary sector partners, public health and the Office for National Statistics, could offer a platform to investigate:

1. The geographical pattern of the post-pandemic backlog in CV services
2. Understand the public health behaviours across different socio-economic backgrounds
3. Track outcomes of disease management with the help of the census data.

The data can then be utilised to guide targeted health campaigns and funding distribution to supplement affected CV services.

Not limiting to organisational partnerships, a close collaboration with patients, both clinically and in research, is equally paramount in addressing disparities in service experience and clinical outcomes. Community-based studies have previously been reported and shown to be effective in addressing gaps in patients’ needs and wants.^6-8 Therefore, CV research needs to foster a culture of patient and public involvement in clinical research activities. Direct public/patient advocate involvement in the research planning and execution can improve the likelihood of developing culturally pertinent research questions and sustainable strategies in tackling multi-faceted CV health inequalities.

Adaptability and sustainability

The adoption of telemedicine and remote home monitoring have allowed cardiology services to maintain the standard of care during the pandemic. Remote care, however, is not a new concept in CV care, in that its role was prominently studied in the chronic heart failure (CHF) cohort since the 2000s. While a meta-analysis of remote care in the CHF cohort concluded promising treatment effects, the heterogeneity of individual studies reminds us to be judicious in selecting patient groups for remote care medicine.⁹ A blanket adoption of virtual care may exacerbate the intrinsic health inequality gap in disadvantaged cohorts with high CV risk and low digital literacy.^10,11 To prevent the exacerbation of such inequalities, cardiology services need to refine triage system models as they look to maintain the uptake of virtual care beyond the pandemic. Cardiology specialists and their local foundation trusts need to establish a safe and equitable framework to risk-stratify patients according to their digital literacy, the status of CV diagnosis and the severity of CVD burden in long-term service planning. Besides service refinement, cardiology societies should proactively embed the topic of digital health equity in their educational curriculum to support current physicians, as well as the next generation of trainees.

Preventability

Fundamental to achieving preventable disparities in CVD outcomes, the cardiology workforce needs to give equal consideration to optimising patient access to guideline-directed treatments. A prominent example is the significant regional variation in the uptake of prognostically beneficial guideline-directed medical therapy (GDMT) and access to cardiac rehabilitation programmes (CR)¹² in CHF cohorts. Leaders in cardiology services should support junior trainees and encourage local quality improvement projects to optimise patient access to GDMT in CHF cohorts. CHF can be complex in its disease process and management for many patients, as such, inequitable access to CR can further widen inequalities in this cohort, with high mortality burden. Low uptake of CR in CHF cohorts can be attributed to several reasons, including missed opportunity, lack of regional access and inadequate recognition of CR as evidence-based management. For instance, there remains no CR for CHF cohorts across Norfolk in 2021. Cardiology leaders from such areas need to proactively advocate for the cause and secure funding to establish the service for the local population. If centre-based options are limited, cardiology centres can now consider an evidence-based CR for use at home to cater for patients who may be limited by geographic barriers.¹³

Conclusion

Although the pandemic has exacerbated inherent health inequalities, it brought about a unique opportunity to embrace novel transformative approaches in CV services. Redefining the concept of health equality in the post-pandemic UK has never been more pertinent. Multi-sectorial stakeholders and the wider health services need to proactively reach out to our patients to create equitable and resilient CV services that are patient centred as we continue to build back better and fairer.

Key messages

• Disparities in cardiovascular morbidity and mortality remain significant despite universal access to healthcare services in the UK
• The concept of proportionate universalism may serve as an alternative care delivery model for addressing health inequalities within cardiology services
• Shared decision-making and partnerships with patients remain paramount in cultivating relevant and sustainable solutions for inequalities within cardiovascular care after the pandemic
• Cardiology services should refine remote care frameworks to safeguard equitable access to best practices, while preventing the exacerbation of intrinsic gaps in the disadvantaged cohorts, who are already burdened with high cardiovascular risk and modest digital literacy

Conflicts of interest

None declared.

Funding

None.

Editors’ note

This article was the prize-winning essay in the National Essay Prize 2021 of the British Junior Cardiologists’ Association (BJCA).

References

1. British Heart Foundation. Heart statistics. Available at: https://www.bhf.org.uk/what-we-do/our-research/heart-statistics [accessed 25 January 2022].

2. Watkinson RE, Sutton M, Turner AJ. Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey. Lancet Public Health 2021;6:e145–e154. https://doi.org/10.1016/S2468-2667(20)30287-5

3. Herbert BM, Johnson AE, Paasche-Orlow MK, Brooks MM, Magnani JW. Disparities in reporting a history of cardiovascular disease among adults with limited English proficiency and angina. JAMA Netw Open 2021;4:e2138780. https://doi.org/10.1001/jamanetworkopen.2021.38780

4. Johnson AE, Birru Talabi M, Bonifacino E et al. Considerations for racial diversity in the cardiology workforce in the United States of America. J Am Coll Cardiol 2021;77:1934–7. https://doi.org/10.1016/j.jacc.2021.02.043

5. Nivet MA. Commentary. Diversity 3.0: a necessary systems upgrade. Acad Med 2011;86:1487–9. https://doi.org/10.1097/ACM.0b013e3182351f79

6. Ekezie W, Czyznikowska BM, Rohit S et al. The views of ethnic minority and vulnerable communities towards participation in COVID-19 vaccine trials. J Public Health (Oxf) 2020;43:e258–e260. https://doi.org/10.1093/pubmed/fdaa196

7. Khunti K, Routen A, Patel K et al. Focused action is required to protect ethnic minority populations from COVID-19 post-lockdown. Br J Gen Pract 2020;71:37–40. https://doi.org/10.3399/bjgp21X714581

8. Highton PJ, Hadjiconstantinou M, Schreder S, Seidu S, Davies M, Khunti K. COVID-19, ethnicity and cardiometabolic disease self-management in UK primary care. Diabetes Metab Syndr 2020;14:2241–3. https://doi.org/10.1016/j.dsx.2020.11.013

9. Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JGF. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev 2015;2015:CD007228. https://doi.org/10.1002/14651858.CD007228.pub3

10. Neves AL, van Dael J, O’Brien N et al. Use and impact of virtual primary care on quality and safety: the public’s perspectives during the COVID-19 pandemic. J Telemed Telecare 2021:[online first]. https://doi.org/10.1177/1357633X211066235

11. Vas V, North S, Rua T et al. Delivering outpatient virtual clinics during the COVID-19 pandemic: early evaluation of clinicians’ experiences. BMJ Open Qual 2022;11:e001313. https://doi.org/10.1136/bmjoq-2020-001313

12. British Heart Foundation. Heart failure: a blueprint for change. London: BHF, 2020. Available from: https://www.bhf.org.uk/what-we-do/policy-and-public-affairs/transforming-healthcare/heart-failure-report

13. Dalal HM, Taylor RS, Jolly K et al. The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: the REACH-HF multicentre randomized controlled trial. Eur J Prev Cardiol 2018;26:262–72. https://doi.org/10.1177/2047487318806358