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Counting Patients’ Social Determinants of Health Could Help Prevent Fatal Heart Attacks

Black man sitting on table talking to white female doctor in brightly-lit exam room

Thomas Barwick

Key Takeaways

  • A 10-year study shows 3 or more social determinants of health put people at risk for death from stroke or heart attack.
  • Minority race, lower income, and lack of health insurance are examples of social determinants of health analyzed in the study.
  • Researchers say accounting for these determinants is critical in physician-patient care—it's not just the problem of a social worker.

Researchers at Weill Cornell Medicine and New York-Presbyterian hospital wanted to know to what extent social and economic barriers to healthcare impact wellness. Over the course of 10 years, they tracked health outcomes in 22,000 people, even visiting individuals who lived over an hour from a large academic medical facility in their homes. Ultimately, the results were striking: People with a certain number of socioeconomic barriers to care had a much greater risk of death from stroke or heart disease than those without barriers. 

Specifically, researchers were looking at something called social determinants of health, and patients with three or more social determinants of health had a 67% greater risk of death from coronary heart disease than those without similar obstacles to health care. The results of the study, using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) project, were published in the journal Circulation in January, 2021.  

What Are Social Determinants of Health?

According to the Office of Disease Prevention and Health Promotion, social determinants of health are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”

The social determinants of health researchers focused on included:

  • Being Black
  • Social isolation
  • Less education (did not graduate from high school)
  • Lower annual household income (household income of less than $35,000 per year)
  • Living in a zip code with high poverty rates
  • Lacking health insurance
  • Living in one of nine U.S. states with limited public health infrastructure (LA, NM, MS, NV, SC, FL, AR, TX, TN)

“The fundamental concept to understand is that social determinants have a greater influence on health outcomes than access to healthcare,” lead study author Monika M. Safford, MD, tells Verywell. “In areas where there are more opportunities, there is better health, but there’s still a lot of work that needs to be done. Affordability of medications, healthy foods, physical activity—all of these things are very different for individuals living in inner cities and poorer neighborhoods. You can tell them they need to improve their diets, but that doesn’t mean they can afford the food. If you keep making recommendations, and they can’t follow through, then you increase the divide and barriers to care.”

Why This Matters in Everyday Practice

Researchers hope clinicians will be increasingly mindful of a patient’s social determinants of health when making assessments and providing care.

“In recent years, the recognition of social determinants of health has been relegated to population health managers, non-physicians, and others not engaged in clinical care,” Safford says. “As a result, most doctors think of social determinants as someone else’s issue to pay attention to, such as social workers. Physicians can modify their clinical care management based upon the social determinants of health.”

This is something Alexa Mieses Malchuk, MD, MPH, a board-certified family physician in North Carolina, is dealing with right now. She adds access to healthy food, toxic stress, language barriers, and difficulty using technology to the list of challenges her patients face. For example, many of her elderly patients are having difficulty signing up for the COVID-19 vaccine online. 

“When you look at health disparities, what you are talking about is social injustice," she tells Verywell. "It has nothing to do with genetics or medications. It has to do with everything that is happening outside the examination room.”

She says that many of her patients are also non-English speaking—a major barrier to health care in the United States.

“For non-English speaking patients, it is nearly impossible to access the healthcare system because a lot of written information is available only in English,” says Mieses Malchuk, who speaks Spanish. “Even if I do not share the same culture, speaking the same language builds trust."

Mieses Malchuk urges that providers use a certified interpreter when communicating with a patient who speaks a different language from their own. Relying upon family members to interpret during visits creates possible issues with inaccurate translation and confidentiality breaches.

Mieses Malchuk adds she takes a “team approach” to care, leaning upon dieticians, social workers, mental health professionals, physical therapists, and others in building long-term relationships with patients and family members.

“Partnerships with people outside the clinic need to be valued in our healthcare system,” she says, emphasizing these partnerships include social services. 

“If you look at the U.S., overall, we spend more money than any other country in the world but we don’t have better health outcomes,” she says. “Countries that have better health outcomes are spending more money on social services. Programs like SNAP and WIC have the power to impact health.” 

Alexa Mieses Malchuk, MD, MPH

[Health disparities] have nothing to do with genetics or medications. It has to do with everything that is happening outside the examination room.

— Alexa Mieses Malchuk, MD, MPH

How Can This Study Help Future Patients?

Safford says that over the next four years, the REGARDS study team plans to expand its list of social determinants of health, including transportation time to a healthcare facility.

“Certain individuals may need to take public transportation,” she says. “While they live five miles away [from a hospital] it could still take two hours to get to their doctor,” she says. 

REGARDS researchers also want to include more variables that reflect structural racism, housing and segregation, and what percentage of the community voted.

A long-term goal of REGARDS research is to create a tool clinicians can use to proactively identify and address social determinants of health in primary care, Safford says. It could be a matter of life or death.

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  1. Safford MM, Reshetnyak E, Sterling MR, et al. Number of social determinants of health and fatal and nonfatal incident coronary heart disease in the REGARDS study. Circulation. 2021;143(3):244-253. doi: 10.1161/CIRCULATIONAHA.120.048026

  2. Weill Cornell Medicine. Stroke and heart failure risk rises with factors like race, education level and neighborhood poverty. Published August 27, 2020.