医疗保险受益人的历史红线划定、社会经济困境与心力衰竭风险。
Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.
机构信息
Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH (A.M., M.Y.D., V.M.).
Division of Epidemiology, UC Berkeley, School of Public Health, CA (M.S.M.).
出版信息
Circulation. 2023 Jul 18;148(3):210-219. doi: 10.1161/CIRCULATIONAHA.123.064351. Epub 2023 Jul 17.
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]; <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]; =0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (<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]; =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.
背景
历史上的红线政策与结构性种族主义有关，其与白人和黑人个体的当代心力衰竭（HF）风险之间的关联尚未得到充分证实。
方法
我们旨在评估红线政策与医疗保险受益的白人及黑人 HF 风险之间的关联。每个邮政编码的红线历史比例是通过使用 Mapping Inequality Project 确定的，邮政编码级别的红线通过每个邮政编码内历史上的红线区域比例来确定。使用广义线性混合模型，分别在白人及黑人医疗保险受益人群中，根据邮政编码级别的社会剥夺指数的潜在混杂因素调整后，评估较高邮政编码红线比例（四分位数 4 与四分位数 1-3）与 HF 风险之间的关联。
结果
共纳入 2388955 名医疗保险受益人（黑人 n=801452；白人 n=1587503；平均年龄 71 岁；男性占 44.6%）。在调整年龄、性别和合并症后，黑人受益人群中居住在红线比例较高的邮政编码（四分位数 4 与四分位数 1-3 相比）与 HF 风险增加相关（风险比，1.08 [95%CI，1.04-1.12]；<0.001）。在进一步调整区域级别的社会剥夺指数后，该关联仍然显著（风险比，1.04 [95%CI，1.002-1.08]；=0.04）。红线比例和社会剥夺指数之间存在显著的交互作用（<0.01），即只有在社会经济困难地区（社会剥夺指数高于中位数），较高的红线比例才与 HF 风险显著相关。在白人受益人群中，在调整年龄、性别和合并症后，红线与 HF 风险降低相关（风险比，0.94 [95%CI，0.89-0.99]；=0.02）。
结论
历史红线与黑人患者 HF 风险增加相关。当代邮政编码级别的健康社会决定因素改变了红线与 HF 风险之间的关系，在社会经济最不利的社区中，红线与 HF 之间的关系最强。
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