Perspective from Pedro R. Moreno, MD, FACC
Disclosures: Khatana reports he received grants from the NHLBI. Please see the study for all other authors’ relevant financial disclosures. Weeks and Weinstein are employees of Microsoft.
February 02, 2021
4 min read
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Regional improvement in economic prosperity tied to slight reduction in CV death

Perspective from Pedro R. Moreno, MD, FACC
Disclosures: Khatana reports he received grants from the NHLBI. Please see the study for all other authors’ relevant financial disclosures. Weeks and Weinstein are employees of Microsoft.
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County-level improvements in markers for economic prosperity such as median employment, housing occupancy, income and education may be associated with reductions in CV death, researchers reported.

According to data published in JAMA, counties for which these variables stagnated experienced little to no change in CV death, whereas counties that saw improvements in economic prosperity experienced notable reductions in CV mortality.

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“The post-recession period in the U.S. has seen the rise of ‘deaths of despair’ (eg, deaths from drug poisoning, suicide, alcoholic liver disease), which have also been attributed to worsening social cohesion,” Sameed Ahmed M. Khatana, MD, MPH, instructor in the division of cardiovascular medicine at the Perelman School of Medicine, and colleagues wrote. “This study suggests that in certain areas of the country, a relative decrease or stagnation in economic prosperity was associated with mortality from causes beyond those typically considered as deaths of despair.”

For the retrospective analysis that included 3,123 U.S. counties, researchers used data from the National Center for Health Statistics to determine the association between change in seven markers of economic prosperity and county-level CV mortality among those aged 40 to 64 years. Counties were divided into tertiles based on change in prosperity. The primary outcome was the annual percentage change (APC) in county-level, aggregated, age-adjusted CV mortality rates per 100,000 individuals.

The seven markers of economic prosperity were:

  • housing occupancy rate;
  • ratio of the county median household income to state median household income;
  • percentage of 25-to-64-year-old adults working;
  • percentage of the adult population with a high school education;
  • percentage of the population with income above the poverty threshold;
  • percentage change in the number of business establishments between the first and last years of the time period; and
  • percentage change in the number of jobs between the first and last years of the time period.

Changes in economic prosperity and CV death

Among the 102,660,852 residents included (51% women), researchers observed 979,228 CV deaths from 2010 to 2017.

According to the study, the age-adjusted rate of CV mortality did not change from 2010 to 2017 in counties in the lowest tertile for change in economic prosperity, with a mean rate of 114.1 deaths per 100,000 individuals in 2010 and 116.1 deaths per 100,000 individuals in 2017 (APC = 0.2%; 95% CI, 0.3 to 0.7).

In counties within the intermediate tertile of change in economic prosperity, CV death decreased from 104.7 per 100,000 individuals in 2010 to 101.9 deaths per 100,000 individuals in 2017 (APC = 0.4%; 95% CI, 0.8 to 0.1), the researchers wrote.

Even greater reductions in CV mortality were observed for highest tertile for change in prosperity, with 100 deaths per 100,000 individuals decreasing to 95.1 deaths per 100,000 individuals (APC = 0.5%; 95% CI, 0.9 to 0.1).

“There may be multiple mechanisms by which economic factors influence health. Job insecurity and income volatility may be associated with cardiovascular events,” the researchers wrote. “Worsening economic prosperity may lessen social cohesion and increase income inequality, contributing to a community’s health.

“Possible biological mechanisms for how economic stress can worsen cardiovascular health include upregulation of inflammation. It is also possible that worsening economic prosperity may lead healthy individuals to emigrate, resulting in higher mortality rates for the remaining population,” the researchers wrote. “Counties in the lowest tertile for change in economic prosperity had a declining population; however, the analysis accounted for changes in age structure as well as changes in the prevalence of two important cardiovascular risk factors: diabetes and obesity.”

According to the study, after adjustment for baseline prosperity, demographic and health care variables, each 10-point higher mean rank for change in economic prosperity was associated with an 0.4% decrease in CV death per year (95% CI, 0.2-0.6).

“These results may not be generalizable beyond the study period of 2010 to 2017 and may not reflect the potential influence that economic distress related to the COVID-19 pandemic may have on cardiovascular mortality,” the researchers wrote.

Lasting effects of the COVID-19 pandemic

“Because vulnerable populations that live in less prosperous areas are more likely to work in low-wage occupations, they have been more severely affected by the economic hardship created by the COVID-19 pandemic,” William B. Weeks, MD, PhD, MBA, senior principal research manager in the precision population health group at Microsoft Health, and James N. Weinstein, DO, MS, senior vice president for Microsoft Healthcare, wrote in a related editorial. “The findings reported by Khatana et al also suggest that without economic intervention, health disparities experienced by vulnerable populations might widen as a consequence.

“Disparities that the coronavirus disease 2019 pandemic have highlighted present opportunities that must not be wasted,” Weeks and Weinstein wrote. “It is imperative that city, state and federal policymakers support direct and indirect mechanisms to address the severe shortcomings of the U.S. health care system by funding additional research, leveraging ongoing community efforts to address social inequities, and developing public-private alliances that can continue the work into the future. Directly stimulating sustainable economic growth in low prosperity areas, incentivizing coalitions of investors that can rebuild those areas, and improving access to high-quality care in low-prosperity areas hold promise for improving the health of the population, reducing health care waste, and potentially propelling the U.S. into a more perfect, more tranquil and more equitable union.”

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