Abstract
BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 210-219 |
| Number of pages | 10 |
| Journal | Circulation |
| Volume | 148 |
| Issue number | 3 |
| DOIs | |
| State | Published - Jul 18 2023 |
Funding
The present research was funded in part by philanthropic gifts by the Haslam Family, Bailey Family, and Khouri family to the Cleveland Clinic (principal investigator Dr Desai). Dr Pandey has received research support from the National Institute on Aging Grant for Early Medical/Surgical Specialists’ Transition To Aging Research Grant (1R03AG067960-01), and the National Institute on Minority Health and Disparities (R01MD017529). Dr Powell-Wiley is funded by the Division of Intramural Research at the National Heart, Lung, and Blood Institute and the Intramural Research Program of the National Institute on Minority Health and Health Disparities. Dr Desai is a consultant for Medtronic and Bristol Myers Squibb. He is on the executive steering committee of a trial sponsored by Bristol Myers Squibb. Dr Pandey has received grant funding outside the present study from Applied Therapeutics and Gilead Sciences; has received honoraria outside the present study as an advisor/consultant for Tricog Health Inc and Lilly, USA, Rivus, and Roche Diagnostics, and has received nonfinancial support from Pfizer and Merck. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institute on Minority Health and Health Disparities; the National Institutes of Health; or the US Department of Health and Human Services. The remaining authors have nothing to disclose.
Keywords
- heart failure
- policies
- race factors
- socioeconomic disparities in health
- systemic racism
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
- Physiology (medical)
