Race and Neighborhood Social Determinants of Cardiovascular Disease Mortality in California Adults Before and During the COVID-19 Pandemic.

Abstract

This study investigated social determinants of cardiovascular disease mortality and effect modification by race/ethnicity, age, and sex before and during the COVID-19 pandemic in Californians aged ≥18 years. The Healthy Places Index is a composite of 23 indicators of neighborhood economic conditions, education, transportation, housing, social capital, environmental pollution, built environment, and access to health care. In this cross-sectional study, 615,295 cardiovascular disease deaths were aggregated to 2010 census tracts from death certificates and populations from U.S. census, 2015-2021. Death rates were age adjusted and stratified by Healthy Places Index deciles, sex, and race/ethnicity, and segmental regression was used to describe Healthy Places Index-cardiovascular disease dose-response relationship. Cardiovascular disease mortality rates in 2015-2019 were inversely associated with Healthy Places Index and declined by 5.4% per Healthy Places Index decile. The rate ratio between the 1st and 10th decile (reference) was 1.77 (95% CI=1.71, 1.83) for all cardiovascular disease, 2.24 (95% CI=2.12, 2.36) for ischemic heart disease, 2.01 (95% CI=1.84, 2.2) for hypertensive heart disease, and 1.41 (95% CI=1.30, 1.52) for stroke. The prepandemic Healthy Places Index-cardiovascular disease mortality gradient was unaltered in the pandemic period (2020-2021). Differences in mortality rates between the highest and lowest Healthy Places Index decile within race/ethnicity groups were larger than differences between race/ethnicity groups. The Healthy Places Index-attributable fraction of cardiovascular disease mortality was 0.28. The pandemic did not change pre-existing disparities in cardiovascular disease mortality associated with social determinants of health. There are untapped opportunities to integrate area-based socioeconomic measures in public health surveillance and population health monitoring in health care and to reinforce policies and programs that reduce cardiovascular disease health inequities.