Health Disparities in Pulmonary Arterial Hypertension and the Impact of the COVID-19 Pandemic
Year: 2021
Type: article
Abstract: The COVID-19 pandemic and coinciding events of 2020 involving political and social instability have put additional strain on the United States (US) population, highlighting and widening health disparities experienced by minoritized and marginalized patients.1 The disproportionate effects of COVID-19 on vulnerable populations may represent deeper systemic challenges of interrelated known and unknown variables contributing to health inequities. To date, the research addressing health disparities in pulmonary arterial hypertension (PAH) has been limited.2,3 In this article, we will explore potential contributing factors to health disparities in PAH. We hope to shed some light on areas of influence or intervention that may need further investigation to improve quality of care and outcomes in PAH.Pulmonary hypertension (PH) is characterized by increased pulmonary arterial pressures.4 The World Health Organization (WHO) categorizes etiologies of PH into 5 groups. WHO Groups 2–5 PH are common and serious.4–6 WHO Group 1 PAH remains classified as an orphan disease associated with many underlying causes5,6 and has an estimated 2.8-year median survival if left untreated.7,8 Since 1980, hospitalization and death rates from PAH have increased because of increased diagnosis and improved reporting patterns, but the total number of cases remains underestimated due to difficulties in disease detection.9–11 PAH remains underrecognized, with many patients being diagnosed more than 2 years after symptom onset, thereby contributing to worse outcomes and missed opportunities to intervene before the occurrence of irreversible life-threatening disease progression.2,12,13 With advances in PAH therapies, treatment is becoming more complex, requiring a more individualized approach.6 By disproportionately impacting vulnerable patients, the delay to diagnosis and the barriers to introducing therapies have the potential to worsen health disparities in PAH, especially when compounded by the challenges facing patients and families during the COVID-19 pandemic.Discrepancies in health outcomes in people with PAH based on race, ethnicity, gender, age, and socioeconomic status (SES) have been demonstrated.11,14–20 Researchers have shown that women have better survival than men with PAH, possibly due to different etiologies, hormonal differences, and other unknown reasons.14,21,22 However, because the risk and prevalence of PAH is higher in women, the overall death rate secondary to PAH remains higher in women.2 The data regarding the impact of race have been conflicting. Authors of some studies have shown that African American or Asian patients with PAH have an increased risk of death.16,18 However, analysis of the REVEAL Registry found no significant association between race or ethnicity and survival in PAH after correcting for variables of prognostic impact.23 A review of vital statistics data from 1994–1998 revealed that African Americans with PAH exhibited substantially higher mortality rates compared to White populations, and African-American women had the highest mortality rates across all ages.15 Underlying causes for these differences are unknown but could be related to social determinants of health (SDHs) and health inequities.3There is some disagreement surrounding the definition and use of the term “disparity.”24,25 For this article, we use the definition provided by Healthy People 2020, which defines health disparity as: “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. . . [that] adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; SES; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”26,27SDHs and how they intersect as well as other determinants of health are important to consider, as they influence health outcomes and, when overlooked, could negatively impact the health of some populations more than others.28 The difficulty in categorizing these factors and the likelihood of disagreement with a preconceived classification demonstrate how complicated these factors and their interrelationships are (Figure 1). Many studies suggest links between inequities in psychosocial, economic, environmental, lifestyle, behavioral, experiential, technological, and biological factors and health that may contribute to health disparities.2,3,26–31 We have designated the information into the following groupings for organizational purposes, but a great deal of overlap exists between the topics of each paragraph.The COVID-19 pandemic is exacerbating stress, which makes it more difficult for marginalized groups to cope with discrimination, who in turn engage more in health-harming behaviors and less in health-promoting behaviors, which further increases the risk of poorer health outcomes. A rich source of social science literature conceptualizes racism, but integration of this research into medical and scientific literature geared toward health professionals is lacking, especially as it pertains to PAH.32Structural racism refers to the totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems (in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, and so on) that in turn reinforce discriminatory beliefs, values, and distribution of resources, which together affect the risk of adverse health outcomes.32 Racism and discrimination of minority and marginalized groups contributes to poorer mental and physical health outcomes, and these subsequent health disparities are increasingly relevant to the care of patients with PAH. Perceived racial and ethnic discrimination leads to negative stress. Emotional responses are known to be associated with long-term health consequences in cardiovascular disease and hypertension and are worth exploring in PAH.2,31,33–41 Cardiovascular and psychological stress responses occur from the mere anticipation of prejudice.42 Prior literature indicates a dose-response relationship between poor health and racial discrimination.41 Everyday discrimination is harmful to the physical and mental health of racial and ethnic minorities as well as Whites, indicating that the connection between health and perceived discrimination goes beyond racial discrimination.38,43 Some potential pathways for negative health outcomes due to discrimination include economic and social deprivation, lack of access to adequate medical care, inequitable exposures to hazards, targeted marketing of substances that can harm health, barriers to engaging in healthy behaviors, and maladaptive coping mechanisms such as substance use.2,29,31,32,35,44–47 Many of these socioeconomic factors shaped by discrimination already contribute to an increased risk for PAH and also put some groups at greater risk for COVID-19,48 demonstrating an intersectionality between these two disease states.African Americans are also at increased risk for other conditions that are known to be risk factors for PAH, such as sickle cell disease, systemic sclerosis, human immunodeficiency virus (HIV), and liver disease.49 The health inequity becomes even more exaggerated because of the disproportionately higher amounts of health-harming products targeted at African-American and minority communities. Such products include alcohol, carbonated and sugar-sweetened beverages, high-fat foods, candy, other high-sugar desserts, and tobacco, including more harmful tobacco products such as mentholated cigarettes.31 Targeted marketing toward minority communities of illegal substances like illicit opioids and heroin also occurs.32 Methamphetamine use has increased since the start of the pandemic, and since liver disease and illegal drug use (methamphetamine, cocaine) are risk factors for PAH, these discriminatory elements are important to consider in PAH and may prove to be a barrier to cessation of substances of abuse.4Much of the available research on discrimination addresses the impact on racial and ethnic minorities. However, many other forms of discrimination exist that impact older adults, women, people with disabilities, gay, lesbian, bisexual, transgender individuals, prisoners, and many others.50 Very little research has been done with regard to the effects or prevalence of discrimination in PAH. Transgender individuals have an increased likelihood of being victims of discrimination and hate crimes and are often socially marginalized, thereby increasing their risk for unemployment, homelessness, and illegal activities such as sex work.38,51 Transgender people, sex workers, and prisoners encounter more daily and severe discrimination and are at a greater likelihood of participating in health-harming behaviors like smoking, drug and alcohol abuse, in addition to attempted suicide, which increases their risk for poor health.38,51 Also, a higher prevalence of HIV infection, mental health issues, suicidal ideation, substance abuse, and exposure to violence exists among these groups.38 Because HIV and intravenous drug use are risk factors for PAH and have a worse prognosis than other forms of PAH, further research into the effect discrimination is having on PAH prevalence, time to diagnosis, prognosis, mortality, and other health outcomes in marginalized populations is warranted.4Black Americans have been found to be exposed to more cumulative stress, which is in turn associated with greater social isolation.52 People who are more socially isolated and have fewer social interactions with others are more likely to die prematurely and have worse mental and physical health.41,52 Social isolation has been found to decrease the benefits of social support and impact overall physical health and systemic inflammation.52 Social support and effective coping skills may help moderate the effects that racial discrimination has on health, which suggests a point of intervention relevant to the management of PAH, which can be targeted by health providers that support the importance of multidisciplinary care and community.34,47Microaggressions are the everyday allegations, slights, and insults that people of color experience regularly in their interactions.53,54 The stress surrounding experiencing microaggressions and discomfort in how to respond have been shown to result in elevated blood pressure. Microaggressions are experienced disproportionately by Black Americans and can result in self-esteem issues and depression.53,54 It is therefore likely that subtle everyday instances of microaggressions also contribute to poorer health outcomes, including in PAH, especially when an increase in microaggressions to minorities has been observed during the COVID-19 pandemic.55Neighborhoods in the US continue to be racially and economically segregated. This form of structured racism contributes to health inequities through environmental exposures, crime, health care, public benefits and resources, housing, education, employment opportunities, and other determinants of health factors.32,40,56 Adverse birth outcomes, decreased longevity, exposure to air pollution, increased risk of chronic disease, poverty, job loss, interpersonal trauma, exposure to violence, and increased rates of crime such as homicide affect health outcomes and are associated with residential segregation and structural racism.32,52Community violence, which includes violence as direct injury, injury of friends or family, witnessing violence, hearing gunshots, and learning about violence through neighbors or media, is rarely enquired about in the care of PAH patients. The physiologic stress response to community violence increases systemic inflammation, and behavioral changes in response to fear of harm can result in decreased physical activity, unhealthy diets, psychoactive substance use, increased and other that influence health as an to cope or of Black Americans affect the mental health of people or to the exposure to community violence likely the stress, and by in particular in populations who already have a chronic disease, such as in access to and adequate public and including foods, and influence health behaviors and are determinants of health contributing to health disparities and may be important factors to consider when healthy changes to patients with PAH. environmental and socioeconomic barriers and to that increase the likelihood of to to medical to and and other environmental and conditions may an important in PAH and are disproportionately exposed to hazards, and and are in or marginalized, groups and African Americans may be to higher or of from the REVEAL Registry median a higher of Black and in the and the with and PAH at in the Also, a time to disease found in the but a time to disease associated with geographic is a of health and can influence and as well as research in PAH has shown an association between worse outcomes and so further investigation of determinants of health in PAH are worth and have been as causes health disparities and racial differences in often factors that can behaviors such as education, health and refers to the of and the of among of a community and like a of a job such as being less for the and fewer are additional challenges and likely contribute to chronic stress and health outcomes from social has been linked to physical In these contribute to less of a and more when with a chronic disease such as PAH. Researchers of PAH suggest an association between and worse outcomes in A is associated with a higher risk of death in This association is of and of that could to disparities in health include the social and physical also has behavioral the likelihood of activities such as and A of risk and of disease impact or and the of an intervention which can result in outcomes between different socioeconomic groups in may an already of patients, which may have a negative impact on PAH outcomes. The economic impact of the COVID-19 pandemic has had disproportionate impact on groups and minority thereby the health disparities already observed in PAH these groups. the increased mortality risk associated with PAH observed in groups can be by that delay in may be a contributing this is However, with may lack health and education, thereby access to care with subsequent increased risk factors that contribute to less activity, more and in turn worse refers to the potential negative effects on communities by on human health, such as disease The for and Social is a to help communities that may need support when a to the pandemic is the COVID-19 which the with additional to the communities that may experience the social and economic are by public health but can be by and with PAH to patients at greater risk due to the pandemic that may need for additional social and mental health of have been associated with a greater chronic disease worse health outcomes, and less to health with higher of being diagnosed with disease than with higher of People who at are 2 to more likely to have adverse health outcomes than people who at higher barriers can result in health racial discrimination, and patients in the US with which can to treatment and health The COVID-19 pandemic has this health which could be due to the increased on the health care as a as well as the increase in use of to care for patients with need to be and in health that are to to less effective medical of or lack of access to Such can result in time and in medical In the of the COVID-19 pandemic and the increase in use, medical and likely further health especially for individuals with medical such as PAH. To and for the and a multidisciplinary medical and social is A to health inequities for minority patients and improve care includes and skills to and and ethnic minorities are at greater risk of access to health care lack of health and of poorer quality medical care due to racial and in status and access may minorities in the US fewer and quality care across all and color have been shown to influence and is compounded by the COVID-19 pandemic because of the that African Americans less for when are This is for a disease such as PAH, which on for and patients, especially since diagnosis and management in PAH are so to this of decreased in minorities to less to PAH is worth is in to PAH this also result in less or access to care has been by the to care during the COVID-19 of care can help health and social inequities and improve overall health, especially in PAH. African-American have been shown to less in health behaviors and have health care which could be related to discrimination and rates of care are higher in and African have been to time to diagnosis in PAH by and increasing access to racism has been associated with and health Racism is therefore we in to time to PAH are to help patients the health care to improve their outcomes, for by their patients with care for care, and and their patients to use health when they need In increasing and by care diagnosis in PAH to help improve time to diagnosis, and management of PAH can improve PAH health outcomes and or decrease health have poorer with minorities especially in and have been linked to poor care and poor especially among Black A but important to this is the health care including PAH to more and social risk to increase among research and health care providers are by the American of Researchers have that even from socioeconomic have a higher likelihood of with racial in the relationship has been associated with better overall health outcomes, to medical and The US is becoming increasingly and that populations will the of the US in fewer than To increase among PAH by PAH in the will impact the PAH can the of the increasing prevalence of to the poor experienced by marginalized individuals in health care and in health is addressing and and by health care It is but worth that about of health care providers which is about the observed in the are and often Researchers on have shown they may affect medical and quality of with health or of and surrounding interactions with minorities contribute to disparities in health and has been associated with greater and less and negative less of patients in treatment poorer and poorer association more racial less social and as well as more in of discrimination in health care may result in less to medical care, and health In has been with increased by patients, which is linked to better of care and greater such as COVID-19 and PAH which disproportionately affect Black populations, the impact of becomes which therefore makes it worth and PAH. Some potential ways to discrimination, and inequity in health care may include increasing education, and a toward that health providers their and or is an intervention with that it can increase of responses is increase toward patients, and decrease of such as stress, and to systemic and the inequitable distribution of health care it is more difficult to health care providers to minoritized and marginalized with fewer and opportunities, are of less may be and have the of as more health care Health systems and providers in these areas may also be more to access for increasing PAH which could result in fewer or to PAH for these patients. This could be contributing to the likely of PAH. The increase in use and of because of the COVID-19 pandemic makes it more for many patients that from care, but if the providers are of the patients for may through the increase in use and in have during the COVID-19 has the potential to or health has increased access to care for PAH patients during the COVID-19 pandemic with of PAH it may have also obstacles to care for patients access to the or with who in areas with or who have may be Researchers suggest and patients are the vulnerable to inequities in care because of inequitable access to in the COVID-19 A found Black people with and as having a less likely to use with had which could be related to a of that further Some potential include or of providers being with and at the point of are to and improve the experience for patients with barriers such as structured of and and available at all of health care to the and is a with lack of access to are the populations that are with poor health outcomes. are for the including between and and health care or with providers are potential investigation in this is barriers that may need to be include the having of the and and decreased use of and by women may be of particular in PAH since is a higher prevalence in women, and it is worth these by the COVID-19 pandemic or if this will be a barrier to in the to and the for being are like other health such as health will continue to be beyond the for in have been provided by the of to help and of information in can information more available to care that could in and With regard to PAH, and could support providers in and to PAH and community resources, especially during the COVID-19 pandemic, when so many patients are at risk of being to due to of and with health in racial differences in treatment of PAH has been in response and treatment with in women and have been in and use in PAH by race and ethnicity have been but the such are on the REVEAL Black patients less likely to be and patients less likely to be patients have been found to be with less in and ethnic minorities are less likely to have health and for minorities with PAH, the lack of health may have the impact on their quality of care and could a in for PAH and in can be requiring a so it is that a exists between PAH patients with health for PAH of diagnosis and PAH research have been by to the pandemic, and into PAH such as the have been This in a risk of PAH patients during a of time when they are at higher risk and when is more likelihood of a greater in health have racial and ethnic It is important for to adequate of minorities and to a geographic of patients. This is a the pandemic is PAH may already be of the PAH patients who are are are have a the health care and and or are to access to PAH PAH may be some of patients because they are less likely to be into due to the of and To the impact of COVID-19 on PAH, including patients, we will need to explore ways of data from other such as death or even in turn in research from an as well as This may an to and ways and of on of socioeconomic suggests that a more is to consider a of risk from a of different of harmful For of patients with PAH have which is higher than of the less than a of the PAH patients with have had their This form of intersectionality an of care providers to be in the management of PAH during and beyond these socially is also a need to consider the of intersectionality to populations with minority or marginalized as well as the of and long-term effects of the COVID-19 pandemic in PAH prevalence, diagnosis, and Since the and of exposure to discrimination, health behaviors, and a of health inequities has been The in and health disparities in PAH involving social health care and among A at of are more harmful than how the harm from may time and increase risk of exposure in events can others in their stress and how social and events in across birth or among with and responses to discrimination among different and gender, of discrimination and PAH may need to consider other marginalized groups and intersectionality as well as these groups The to which effect exists may help to between and as more research in this is COVID-19 pandemic has of in disparities in health care have been including as they to PAH. research to further and explore the between factors contributing to health inequity in PAH and how these have been exaggerated by the social and economic from COVID-19 is to medical professionals on how to barriers and intervene to and health and research are by the
Institutions: University of Utah, Stanford Medicine, Stanford University
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W3128457361