Immigration Status and Medication Use for Cardiovascular Disease Prevention in the United States

The adult immigrant population has doubled from approximately 19 million in 1990 to 42 million in 2017, accounting for 17% of all US adults. However, noncitizens, which account for half of all immigrants, encounter significant barriers to healthcare access. For example, noncitizens without documentation (or undocumented immigrants) are ineligible for publicly funded health insurance, as are many documented immigrants, their eligibility depends on their specific visa status. Noncitizens also disproportionately face structural factors, such as poverty and residence in segregated, underserved communities, that adversely impact health and healthcare access. Therefore, immigration status, conceptualized using both citizenship and documentation status, may contribute to disparities in cardiovascular disease (CVD), the leading cause of morbidity and mortality in this population. Despite the critical role of immigration status and community characteristics on CVD risk factors and their treatment and control, these determinants have largely been ignored in immigrant health research. The dissertation attempts to fill this knowledge gap by investigating: (1) the association between immigration status and the prevalence, treatment, and control of CVD risk factors, (2) the relationship between living in Latino noncitizen communities and preventative cardiovascular medication use, and (3) individual and community level factors that confound these relationships. Using nationally representative data, I found that high cholesterol, hypertension, and diabetes were commonly prevalent among immigrants regardless of citizenship status yet, noncitizens are less likely to be treated or achieve control of these CVD risk factors. Using a population-based cohort of Latino immigrants, I found that undocumented immigrants are less likely to be treated for CVD risk factors. Finally, using all-payer administrative claims in New York City, Los Angeles, and Chicago, I found that living in Latino communities with a greater proportion of noncitizens (i.e., noncitizen communities) is associated with greater nonadherence to statins. Differences in the treatment of CVD risk factors may lead to disparities in CVD morbidity and mortality as immigrants age in the US, therefore, these studies have important implications for policies that intend to reduce the CVD burden among immigrants. More importantly, this research has the potential to shift the line of questioning in immigrant health, a field that has mainly focused on the influence of racial/ethnic, cultural, or behavioral differences. Instead, this work acknowledges the influence of immigration status as a structural factor that can deeply influence health inequities, regardless of these factors. I hope this work broadens the focus of immigrant health research as policymakers need to understand the root causes of disparities in order to design effective interventions

Association Between Pharmacy Proximity With Cardiovascular Medication Use and Risk Factor Control in the United States

Background Poor neighborhood‐level access to health care, including community pharmacies, contributes to cardiovascular disparities in the United States. The authors quantified the association between pharmacy proximity, antihypertensive and statin use, and blood pressure (BP) and low‐density lipoprotein cholesterol (LDL‐C) among a large, diverse US cohort. Methods and Results A cross‐sectional analysis of Black and White participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study during 2013 to 2016 was conducted. The authors designated pharmacy proximity by census tract using road network analysis with population‐weighted centroids within a 10‐minute drive time, with 5‐ and 20‐minute sensitivity analyses. Pill bottle review measured medication use, and BP and LDL‐C were assessed using standard methods. Poisson regression was used to quantify the association between pharmacy proximity with medication use and BP control, and linear regression for LDL‐C. Among 16 150 REGARDS participants between 2013 and 2016, 8319 (51.5%) and 8569 (53.1%) had an indication for antihypertensive and statin medication, respectively, and pharmacy proximity data. The authors did not find a consistent association between living in a census tract with higher pharmacy proximity and antihypertensive medication use, BP control, or statin medication use and LDL‐C levels, regardless of whether the area was rural, suburban, or urban. Results were similar among the 5‐ and 20‐minute drive‐time analyses. Conclusions Living in a low pharmacy proximity census tract may be associated with antihypertensive and statin medication use, or with BP control and LDL‐C levels. Although, in this US cohort, outcomes were similar for adults living in high or low pharmacy proximity census tracts

Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study

Cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke, are the leading cause of global mortality and a major contributor to disability. This paper reviews the magnitude of total CVD burden, including 13 underlying causes of cardiovascular death and 9 related risk factors, using estimates from the Global Burden of Disease (GBD) Study 2019. GBD, an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time, used all available population-level data sources on incidence, prevalence, case fatality, mortality, and health risks to produce estimates for 204 countries and territories from 1990 to 2019. Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI]: 257 to 285 million) in 1990 to 523 million (95% UI: 497 to 550 million) in 2019, and the number of CVD deaths steadily increased from 12.1 million (95% UI:11.4 to 12.6 million) in 1990, reaching 18.6 million (95% UI: 17.1 to 19.7 million) in 2019. The global trends for disability-adjusted life years (DALYs) and years of life lost also increased significantly, and years lived with disability doubled from 17.7 million (95% UI: 12.9 to 22.5 million) to 34.4 million (95% UI:24.9 to 43.6 million) over that period. The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170 to 194 million) DALYs, 9.14 million (95% UI: 8.40 to 9.74 million) deaths in the year 2019, and 197 million (95% UI: 178 to 220 million) prevalent cases of IHD in 2019. The total number of DALYs due to stroke has risen steadily since 1990, reaching 143 million (95% UI: 133 to 153 million) DALYs, 6.55 million (95% UI: 6.00 to 7.02 million) deaths in the year 2019, and 101 million (95% UI: 93.2 to 111 million) prevalent cases of stroke in 2019. Cardiovascular diseases remain the leading cause of disease burden in the world. CVD burden continues its decades-long rise for almost all countries outside high-income countries, and alarmingly, the age-standardized rate of CVD has begun to rise in some locations where it was previously declining in high-income countries. There is an urgent need to focus on implementing existing cost-effective policies and interventions if the world is to meet the targets for Sustainable Development Goal 3 and achieve a 30% reduction in premature mortality due to noncommunicable diseases

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. W measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. Interpretation Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BackgroundHealth-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.MethodsWe distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.FindingsBetween 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.InterpretationAlthough major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.FundingBill & Melinda Gates Foundation