- Email: [email protected]
Cultural Third World War
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL.
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2016
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2016.10.004
EDITOR’S PAGE
Cultural Third World War How Economic Disparity Adversely Affects Health Valentin Fuster, MD, PHD
“When man is viewed in his totality.we are able
income bracket (7) (Figure 1). Moreover, according to a
to have a profound understanding of the poorest,
2010 Census Bureau measure, the national poverty
those most in need, and the marginalized. In this
rate increased by 3.3 percentage points, or by
S
way, they will benefit from your care and
approximately
the support and assistance offered by the
incomes were adjusted for out-of-pocket medical
public and private health sectors.”
costs (7) (Table 1). These factors are linked to a wide
10
million
people,
when
family
—Excerpt from Pope Francis’s address
range of health problems, including low birth weight,
to the 2016 European Society of
cardiovascular disease, hypertension, arthritis, dia-
Cardiology Congress in Rome, Italy (1) ocioeconomic
status
underlies
3
major
determinants of health: access, environmental exposure, and behavior (2). Lower socioeco-
nomic status is also associated with higher mortality, with the greatest disparities occurring in middle adulthood (age 45 to 65 years) (2–5). In fact, according to calculations from the U.S. National Longitudinal Mortality Survey, people whose family income in 1980 was >$50,000, putting them in the top 5% of incomes, had a life expectancy at all ages that was approximately 25% longer than those in the bottom 5%, whose family income was <$5,000 (6). Unfortunately, the increasing gap between the rich and the rest (7) in recent decades has only caused a greater divide in the 3 major determinants of health. In addition, there are questions about whether the cost of health care—especially in the United States— contributes to the disparity. Thus, from 1988 to 2012, the average employer-sponsored insurance premium rose, increasing costs to families by >$12,000 (7) (Figure 1). This cost hike represented an increase in 60% of the average annual income for families in the bottom 40% of the population, compared with only 4.5% of overall income for families in the upper
betes, and cancer (2,8). Reducing socioeconomic disparities related to health will require national and international policy initiatives addressing the components of socioeconomic status, such as income, education, and occupation, as well as the pathways by which these affect health (1). Importantly, in addition to policy reforms to combat this crisis, through our ability to educate, editors of medical journals have a role and responsibility to lessen this drastic class divide that leads to disparate care and declining health of certain lower-income individuals and communities. In my view, peer-reviewed medical journals have the potential to help change this widening gap between “the rich and the rest” (7). As Editor-in-Chief of JACC, I have consistently written about the importance of health promotion, rather than only focusing on costly treatments for advanced disease states (9,10). The JACC Editorial Board has chosen to publish trials focusing on economical approaches of disease prevention that can help cardiovascular specialists and general practitioners consider new approaches for sustainable positive outcomes. For instance, the Colombian Initiative, which has since evolved into the SI! Program, enrolled 1,043 preschool-age children who were provided classroom educational and playful activities during 5 months to obtain a mean change in children’s knowl-
From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn
edge, attitudes, and habits (KAH) related to healthy
School of Medicine at Mount Sinai, New York, New York.
eating and living an active life-style (11). Most of the
2
Fuster
JACC VOL.
-, NO. -, 2016 -, 2016:-–-
Editor’s Page
F I G U R E 1 Rising Health Insurance Premiums Disproportionately Affect Low-Wage Workers
Family income: bottom 40%
Family income: top 5%
$40,000
$400,000
$35,000
$350,000
$357,137
$352,338
$318,059 $30,000
$28,732
$27,975
$29,168
$300,000 $26,859
$257,572
$25,000
$250,000
$20,000
$200,000 $15,745
$15,000
$150,000 $11,404
$10,000
$100,000
$7,754 $3,660
$5,000
$50,000 $3,660
$0
$7,754
$11,404
$15,745
$0 1988
1996
2004
2012
Family income
1988
1996
2004
2012
Average employer-sponsored family premium
All figures are adjusted for inflation (2012 U.S. dollars; BLS Urban Consumer Price Index). Data for family income—U.S. Census Bureau, includes only “money income” and not employer benefits. Data for average employer-sponsored family premium: Kaiser Family Foundation/HRET Survey of Employer-Sponsored Health Benefits 2004 & 2012; KPMG Survey of Employed-Sponsored Health Benefits, 1996; and Health Insurance Association of America 1988. Reproduced with permission from Blumenthal and Squires (7).
participants came from low socioeconomic back-
prevention methods represent an opportunity, espe-
grounds in female-led households. Although the KAH
cially in low- and middle-income communities, to
improved at 3 years across age groups (age 3 to 5 years)
counteract the massive disparity between the classes
and sex, there was also a positive improvement in
with health care considerations.
the nutritional status of the participants, compared
In addition, JACC published the FOCUS (Fixed-Dose
with the control group. This SI! Program has now
Combination Drug for Secondary Cardiovascular Pre-
randomized 2,062 children, ranging from age 3 to 5
vention) trial, an observational, prospective, cross-
years (12), and after 3 years of follow-up, the KAH
sectional study designed to assess the relationship of
score was significantly higher in children in the inter-
a variety of factors—including socioeconomic, clinical,
vention group compared with the control group. The
and psychosocial factors—with patients’ adherence to
project more recently expanded to Harlem, New York,
medical treatment in 5 countries (Argentina, Brazil,
in collaboration with the American Heart Associa-
Italy, Paraguay, and Spain). In addition to individual-
tion (13). These types of early life-style, primary
ized
patient
information,
the
researchers
also
collected data regarding the national health systems and various economic indicators for each country, T A B L E 1 Changes in Supplemental Poverty Measure After Adjusting for
Out-of-Pocket Health Care Costs, 2010
standard drugs for secondary cardiovascular preven-
Percent in Poverty Not Adjusted for Health Care Costs
Percent in Poverty Adjusted for Health Care Costs
Total
12.7
Age <18 yrs Ages 18–64 yrs Age $65 yrs Data from Short (16).
including accessibility, cost, and affordability of the
Additional People in Poverty After Adjustment
tion (aspirin, statin, angiotensin-converting enzyme
16.0
10 million
2,000 subjects: 1,000 in Europe and 1,000 in South
15.4
18.2
2 million
America. The study demonstrated that adherence to
12.4
15.2
5 million
cardiovascular medications is a complex problem,
8.6
15.9
3 million
with many different factors influencing adherence in a
inhibitors, and beta-blocker) (14). The trial included
variety of ways. The single most important factor associated with poor adherence was depression;
JACC VOL.
-, NO. -, 2016
Fuster
-, 2016:-–-
Editor’s Page
yet, lack of social support and complexity of treat-
should target community systems, including quality-
ment also contributed significantly to poor adherence.
improvement initiatives that provide feedback to
The same FOCUS trial results showed that access to a
sites through reporting benchmarking performance,
polypill in patients with cardiovascular disease
specifically in practices serving high proportions of
improved adherence significantly by 22% after 9
patients
months of follow-up. Castellano et al. (14) noted that
types of pragmatic approach and research could
in the setting of low- or middle-income communities
possibly enhance and motivate quality improvement
and in populations with lower use of indicated medi-
programs that are seeking to assist vulnerable
cations, the effect of the fixed-dose combination
populations.
with
low
socioeconomic
status.
These
strategy could serve as a partial solution to the lack of
Although the published medical data alone cannot
adherence, accessibility, and affordability of cardio-
solve the problem of this cultural war, it has its role to
vascular medications.
play, and we should remember the final words of
Under the previous JACC administration, the
Pope Francis at ESC.16 as we approach our re-
board published an observational study from the
sponsibilities each day: “I ask the Lord to bless your
National Cardiovascular Disease Registry’s outpa-
research and medical care, so that everyone may
tient PINNACLE Registry, which noted a marked
receive relief from their suffering, a greater quality of
difference in the use of guideline-recommended
life and an increasing sense of hope” (1).
secondary preventive measures for the treatment of peripheral arterial disease across diverse income
ADDRESS
subgroups, with patients in the lower socioeconomic
Fuster, Zena and Michael A. Wiener Cardiovascular
CORRESPONDENCE
tier receiving less appropriate care (15). As a result of
Institute, Icahn School of Medicine at Mount Sinai,
their findings, Subherwal et al. (15) recommended
One
that future efforts to reduce treatment disparities
York 10029. E-mail: [email protected].
Gustave
L.
Levy
TO:
Place,
New
Dr.
Valentin
York,
New
REFERENCES 1. Pope Francis: Discourse to Cardiology Congress. Available at: http://en.radiovaticana.va/news/ 2016/08/31/pope_francis_dicourse_to_cardiology_ congress/1254760 Accessed September 2, 2016. 2. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs 2002;21:60–76. 3. Mare RD. Socio-economic careers and differential mortality among older men in the U.S. In: Vallin J, D’Souza S, Palloni A, editors. Measurement and Analysis of Mortality—New Approaches. Oxford: Clarendon, 1990:362–87. 4. Lantz PM, House JS, Lepkowski JM, et al. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of U.S. adults. JAMA 1998;279:1703–8. 5. Pappas G, Queen S, Hadden W, et al. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993;329:103–9. 6. Deaton A. Health, income, and inequality. The National Bureau of Economic Research. Available
at: http://www.nber.org/reporter/spring03/health. html. Accessed September 2, 2016. 7. Blumenthal D, Squires D. Do health care costs fuel economic inequality in the United States? September 9, 2014. Available at: http://www. commonwealthfund.org/publications/blog/2014/ sep/do-health-costs-fuel-inequality. Accessed September 2, 2016. 8. Pamuk E, Makuc D, Heck K, et al. Socioeconomic Status and Health Chartbook: Health, United States, 1998. Hyattsville, MD: National Center for Health Statistics, 1998. 9. Fuster V. Global burden of cardiovascular disease: time to implement feasible strategies and to monitor results. J Am Coll Cardiol 2014;64:520–2. 10. Fuster V. The vulnerable patient: providing a lens into the interconnected diseases of the heart and brain. J Am Coll Cardiol 2015;66:1077–8. 11. Céspedes JA, Briceño G, Farkouh ME, et al. Targeting preschool children to promote cardiovascular health: cluster randomized trial. Am J Med 2013;126:27–35e.
12. Peñalvo JL, Santos-Beneit G, Sotos-Prieto M, et al. The SI! Program for cardiovascular health promotion in early childhood: a clusterrandomized trial. 1525–34.
J Am Coll Cardiol 2015;66:
13. Vedanthan R, Bansilal S, Soto AV, et al. Family-based approaches to cardiovascular health promotion. J Am Coll Cardiol 2016;67: 1725–37. 14. Castellano JM, Sanz G, Peñalvo JL, et al. A polypill strategy to improve adherence: results from the FOCUS project. J Am Coll Cardiol 2014; 64:2071–82. 15. Subherwal S, Patel MR, Tang F, et al. Socioeconomic disparities in the use of cardioprotective medications among patients with peripheral artery disease: an analysis of the American College of Cardiology’s NCDR PINNACLE Registry. J Am Coll Cardiol 2013;62:51–7. 16. Short K. The Research Supplemental Poverty Measure: 2010, Current Population Reports. Washington, D.C.: U.S. Census Bureau, 2011.
3
VOL.
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2016
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2016.10.004
EDITOR’S PAGE
Cultural Third World War How Economic Disparity Adversely Affects Health Valentin Fuster, MD, PHD
“When man is viewed in his totality.we are able
income bracket (7) (Figure 1). Moreover, according to a
to have a profound understanding of the poorest,
2010 Census Bureau measure, the national poverty
those most in need, and the marginalized. In this
rate increased by 3.3 percentage points, or by
S
way, they will benefit from your care and
approximately
the support and assistance offered by the
incomes were adjusted for out-of-pocket medical
public and private health sectors.”
costs (7) (Table 1). These factors are linked to a wide
10
million
people,
when
family
—Excerpt from Pope Francis’s address
range of health problems, including low birth weight,
to the 2016 European Society of
cardiovascular disease, hypertension, arthritis, dia-
Cardiology Congress in Rome, Italy (1) ocioeconomic
status
underlies
3
major
determinants of health: access, environmental exposure, and behavior (2). Lower socioeco-
nomic status is also associated with higher mortality, with the greatest disparities occurring in middle adulthood (age 45 to 65 years) (2–5). In fact, according to calculations from the U.S. National Longitudinal Mortality Survey, people whose family income in 1980 was >$50,000, putting them in the top 5% of incomes, had a life expectancy at all ages that was approximately 25% longer than those in the bottom 5%, whose family income was <$5,000 (6). Unfortunately, the increasing gap between the rich and the rest (7) in recent decades has only caused a greater divide in the 3 major determinants of health. In addition, there are questions about whether the cost of health care—especially in the United States— contributes to the disparity. Thus, from 1988 to 2012, the average employer-sponsored insurance premium rose, increasing costs to families by >$12,000 (7) (Figure 1). This cost hike represented an increase in 60% of the average annual income for families in the bottom 40% of the population, compared with only 4.5% of overall income for families in the upper
betes, and cancer (2,8). Reducing socioeconomic disparities related to health will require national and international policy initiatives addressing the components of socioeconomic status, such as income, education, and occupation, as well as the pathways by which these affect health (1). Importantly, in addition to policy reforms to combat this crisis, through our ability to educate, editors of medical journals have a role and responsibility to lessen this drastic class divide that leads to disparate care and declining health of certain lower-income individuals and communities. In my view, peer-reviewed medical journals have the potential to help change this widening gap between “the rich and the rest” (7). As Editor-in-Chief of JACC, I have consistently written about the importance of health promotion, rather than only focusing on costly treatments for advanced disease states (9,10). The JACC Editorial Board has chosen to publish trials focusing on economical approaches of disease prevention that can help cardiovascular specialists and general practitioners consider new approaches for sustainable positive outcomes. For instance, the Colombian Initiative, which has since evolved into the SI! Program, enrolled 1,043 preschool-age children who were provided classroom educational and playful activities during 5 months to obtain a mean change in children’s knowl-
From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn
edge, attitudes, and habits (KAH) related to healthy
School of Medicine at Mount Sinai, New York, New York.
eating and living an active life-style (11). Most of the
2
Fuster
JACC VOL.
-, NO. -, 2016 -, 2016:-–-
Editor’s Page
F I G U R E 1 Rising Health Insurance Premiums Disproportionately Affect Low-Wage Workers
Family income: bottom 40%
Family income: top 5%
$40,000
$400,000
$35,000
$350,000
$357,137
$352,338
$318,059 $30,000
$28,732
$27,975
$29,168
$300,000 $26,859
$257,572
$25,000
$250,000
$20,000
$200,000 $15,745
$15,000
$150,000 $11,404
$10,000
$100,000
$7,754 $3,660
$5,000
$50,000 $3,660
$0
$7,754
$11,404
$15,745
$0 1988
1996
2004
2012
Family income
1988
1996
2004
2012
Average employer-sponsored family premium
All figures are adjusted for inflation (2012 U.S. dollars; BLS Urban Consumer Price Index). Data for family income—U.S. Census Bureau, includes only “money income” and not employer benefits. Data for average employer-sponsored family premium: Kaiser Family Foundation/HRET Survey of Employer-Sponsored Health Benefits 2004 & 2012; KPMG Survey of Employed-Sponsored Health Benefits, 1996; and Health Insurance Association of America 1988. Reproduced with permission from Blumenthal and Squires (7).
participants came from low socioeconomic back-
prevention methods represent an opportunity, espe-
grounds in female-led households. Although the KAH
cially in low- and middle-income communities, to
improved at 3 years across age groups (age 3 to 5 years)
counteract the massive disparity between the classes
and sex, there was also a positive improvement in
with health care considerations.
the nutritional status of the participants, compared
In addition, JACC published the FOCUS (Fixed-Dose
with the control group. This SI! Program has now
Combination Drug for Secondary Cardiovascular Pre-
randomized 2,062 children, ranging from age 3 to 5
vention) trial, an observational, prospective, cross-
years (12), and after 3 years of follow-up, the KAH
sectional study designed to assess the relationship of
score was significantly higher in children in the inter-
a variety of factors—including socioeconomic, clinical,
vention group compared with the control group. The
and psychosocial factors—with patients’ adherence to
project more recently expanded to Harlem, New York,
medical treatment in 5 countries (Argentina, Brazil,
in collaboration with the American Heart Associa-
Italy, Paraguay, and Spain). In addition to individual-
tion (13). These types of early life-style, primary
ized
patient
information,
the
researchers
also
collected data regarding the national health systems and various economic indicators for each country, T A B L E 1 Changes in Supplemental Poverty Measure After Adjusting for
Out-of-Pocket Health Care Costs, 2010
standard drugs for secondary cardiovascular preven-
Percent in Poverty Not Adjusted for Health Care Costs
Percent in Poverty Adjusted for Health Care Costs
Total
12.7
Age <18 yrs Ages 18–64 yrs Age $65 yrs Data from Short (16).
including accessibility, cost, and affordability of the
Additional People in Poverty After Adjustment
tion (aspirin, statin, angiotensin-converting enzyme
16.0
10 million
2,000 subjects: 1,000 in Europe and 1,000 in South
15.4
18.2
2 million
America. The study demonstrated that adherence to
12.4
15.2
5 million
cardiovascular medications is a complex problem,
8.6
15.9
3 million
with many different factors influencing adherence in a
inhibitors, and beta-blocker) (14). The trial included
variety of ways. The single most important factor associated with poor adherence was depression;
JACC VOL.
-, NO. -, 2016
Fuster
-, 2016:-–-
Editor’s Page
yet, lack of social support and complexity of treat-
should target community systems, including quality-
ment also contributed significantly to poor adherence.
improvement initiatives that provide feedback to
The same FOCUS trial results showed that access to a
sites through reporting benchmarking performance,
polypill in patients with cardiovascular disease
specifically in practices serving high proportions of
improved adherence significantly by 22% after 9
patients
months of follow-up. Castellano et al. (14) noted that
types of pragmatic approach and research could
in the setting of low- or middle-income communities
possibly enhance and motivate quality improvement
and in populations with lower use of indicated medi-
programs that are seeking to assist vulnerable
cations, the effect of the fixed-dose combination
populations.
with
low
socioeconomic
status.
These
strategy could serve as a partial solution to the lack of
Although the published medical data alone cannot
adherence, accessibility, and affordability of cardio-
solve the problem of this cultural war, it has its role to
vascular medications.
play, and we should remember the final words of
Under the previous JACC administration, the
Pope Francis at ESC.16 as we approach our re-
board published an observational study from the
sponsibilities each day: “I ask the Lord to bless your
National Cardiovascular Disease Registry’s outpa-
research and medical care, so that everyone may
tient PINNACLE Registry, which noted a marked
receive relief from their suffering, a greater quality of
difference in the use of guideline-recommended
life and an increasing sense of hope” (1).
secondary preventive measures for the treatment of peripheral arterial disease across diverse income
ADDRESS
subgroups, with patients in the lower socioeconomic
Fuster, Zena and Michael A. Wiener Cardiovascular
CORRESPONDENCE
tier receiving less appropriate care (15). As a result of
Institute, Icahn School of Medicine at Mount Sinai,
their findings, Subherwal et al. (15) recommended
One
that future efforts to reduce treatment disparities
York 10029. E-mail: [email protected].
Gustave
L.
Levy
TO:
Place,
New
Dr.
Valentin
York,
New
REFERENCES 1. Pope Francis: Discourse to Cardiology Congress. Available at: http://en.radiovaticana.va/news/ 2016/08/31/pope_francis_dicourse_to_cardiology_ congress/1254760 Accessed September 2, 2016. 2. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Affairs 2002;21:60–76. 3. Mare RD. Socio-economic careers and differential mortality among older men in the U.S. In: Vallin J, D’Souza S, Palloni A, editors. Measurement and Analysis of Mortality—New Approaches. Oxford: Clarendon, 1990:362–87. 4. Lantz PM, House JS, Lepkowski JM, et al. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of U.S. adults. JAMA 1998;279:1703–8. 5. Pappas G, Queen S, Hadden W, et al. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med 1993;329:103–9. 6. Deaton A. Health, income, and inequality. The National Bureau of Economic Research. Available
at: http://www.nber.org/reporter/spring03/health. html. Accessed September 2, 2016. 7. Blumenthal D, Squires D. Do health care costs fuel economic inequality in the United States? September 9, 2014. Available at: http://www. commonwealthfund.org/publications/blog/2014/ sep/do-health-costs-fuel-inequality. Accessed September 2, 2016. 8. Pamuk E, Makuc D, Heck K, et al. Socioeconomic Status and Health Chartbook: Health, United States, 1998. Hyattsville, MD: National Center for Health Statistics, 1998. 9. Fuster V. Global burden of cardiovascular disease: time to implement feasible strategies and to monitor results. J Am Coll Cardiol 2014;64:520–2. 10. Fuster V. The vulnerable patient: providing a lens into the interconnected diseases of the heart and brain. J Am Coll Cardiol 2015;66:1077–8. 11. Céspedes JA, Briceño G, Farkouh ME, et al. Targeting preschool children to promote cardiovascular health: cluster randomized trial. Am J Med 2013;126:27–35e.
12. Peñalvo JL, Santos-Beneit G, Sotos-Prieto M, et al. The SI! Program for cardiovascular health promotion in early childhood: a clusterrandomized trial. 1525–34.
J Am Coll Cardiol 2015;66:
13. Vedanthan R, Bansilal S, Soto AV, et al. Family-based approaches to cardiovascular health promotion. J Am Coll Cardiol 2016;67: 1725–37. 14. Castellano JM, Sanz G, Peñalvo JL, et al. A polypill strategy to improve adherence: results from the FOCUS project. J Am Coll Cardiol 2014; 64:2071–82. 15. Subherwal S, Patel MR, Tang F, et al. Socioeconomic disparities in the use of cardioprotective medications among patients with peripheral artery disease: an analysis of the American College of Cardiology’s NCDR PINNACLE Registry. J Am Coll Cardiol 2013;62:51–7. 16. Short K. The Research Supplemental Poverty Measure: 2010, Current Population Reports. Washington, D.C.: U.S. Census Bureau, 2011.
3