Evaluation of Factors Underlying Sex-Based Disparities in Cardiovascular Care in Adults With Self-reported Premature Atherosclerotic Cardiovascular Disease

Key Points

Question  Do sex-based differences exist in physical and mental health domains and health care access in adults with self-reported premature atherosclerotic cardiovascular disease (ASCVD)?

Findings  In this cohort study of 748 090 adults aged 18 to 55 years, 28 522 had self-reported premature ASCVD. Compared with men, women were more likely to report being clinically depressed, have cost-related medication nonadherence, have not seen a physician due to cost, and have overall poor physical health.

Meaning  Adults with premature ASCVD, especially women, may benefit from improved access to mental health services and interventions addressing out-of-pocket costs.

Importance  There are limited data regarding sex-based differences in physical and mental health domains and health care access in adults with premature atherosclerotic cardiovascular disease (ASCVD).

Objective  To study the association of sex with physical and mental health domains as well as health care access–related factors among adults with self-reported premature ASCVD.

Design, Setting, and Participants  Retrospective cohort analysis of 748 090 adults aged 18 to 55 years in the Behavioral Risk Factor Surveillance System 2016 to 2019 in the US. Data were analyzed from June to July 2021.

Exposures  Self-reported ASCVD, defined as having a history of coronary artery disease, myocardial infarction, or stroke.

Main Outcomes and Measures  Self-reported physical and mental health and measures of health care access, including self-reported cost-related medication nonadherence and inability to see a physician due to cost.

Results  Between 2016 and 2019, 748 090 adults aged 18-55 years were identified, of whom 28 522 (3.3%) had self-reported premature ASCVD. Of these, 14 358 (47.0%) were women. Compared with men, women with premature ASCVD were more likely to report being clinically depressed (odds ratio [OR], 1.73; 95% CI, 1.41-2.14; P < .001), have cost-related medication nonadherence (OR, 1.42; 95% CI, 1.11-1.82; P = .005), have not seen a physician due to cost-related issues (OR, 4.52; 95% CI, 2.24-9.13; P < .001), and were more likely to report overall poor physical health (OR, 1.39; 95% CI, 1.09-1.78; P = .008) despite being more likely to have health care coverage (85.3% vs 80.8%; P = .04) and a primary care physician (84.2% vs 75.7%; P < .001).

Conclusions and Relevance  Results from this study indicate that women with premature ASCVD were more likely to report worse overall physical and mental health, inability to see a physician due to cost, and cost-related medical nonadherence. Interventions addressing mental health and out-of-pocket costs are needed in adults with premature ASCVD.

Atherosclerotic cardiovascular disease (ASCVD) among young adults is a public health challenge with a worldwide prevalence of 10% to 30%.¹ Despite having higher rates of hospitalization for symptomatic ASCVD, women are less likely to receive guideline-directed treatment,² antiplatelet therapy, and statin therapy and have lower statin adherence compared with men.³ As a result, women with premature ASCVD are more likely to have worse overall outcomes.⁴ Further, poor mental health, medication nonadherence, and lack of health care access have been associated with poor control of cardiovascular risk factors as well as increased risk of ASCVD events.^5-8 Therefore, it is important to determine the extent to which sex-based differences exist in health care access and socioeconomic and mental health–related factors among men and women with premature ASCVD.

We investigated the association of sex with physical and mental health domains, as well as health care access–related factors, including cost-related medication nonadherence and inability to see a physician due to cost among adults with premature ASCVD.

The Behavioral Risk Factor Surveillance System (BRFSS) survey from 2016 to 2019 was used to identify adults aged 18 to 55 years. As BRFSS is a deidentified database, the study was exempt from institutional review board approval, and consent was not required. The presence of cardiovascular comorbidities, including hypertension, dyslipidemia, diabetes, and chronic kidney disease, were self-reported. ASCVD status was ascertained by participants responding to the question “Have you ever had coronary heart disease or myocardial infarction or stroke?” Adults aged 18 to 55 years who answered yes to the above question were considered as having self-reported premature ASCVD.

Physical and mental health domains, sex, race and ethnicity, and medication adherence were self-reported. Details regarding these questions are provided in eTable 1 in the Supplement. The estimates provided by the BRFSS questionnaire, including data on self-reported ASCVD, have been previously validated against other national estimates.^9,10

We analyzed these cross-sectional data using survey weights for BRFSS provided by the US Centers for Disease Control and Prevention. We performed multivariable logistic regression analyses to study the association of sex with physical and mental health domains as well as health care access–related factors among adults with premature ASCVD. Regression models were adjusted for age, race and ethnicity, education, employment, relation to poverty line, and rural residence.

Our study population included 748 090 participants between the ages of 18 and 55 years, of whom 28 522 (3.3%) reported a history of ASCVD. The baseline characteristics of the overall cohort and those with self-reported premature ASCVD stratified by sex are listed in Table 1. Women with premature ASCVD were more often Black, had lower income levels, and were less likely to report hypertension, hyperlipidemia, and diabetes. Women were also less likely to have received emotional support, be dissatisfied with their quality of life, and report higher levels of depression compared with men with premature ASCVD. They were more likely to report an inability to see a physician due to cost and cost-related medication nonadherence, despite being more likely to have health care coverage and a primary care physician. Compared with the overall cohort, both men and women with premature ASCVD were more likely to report an inability to see a physician due to cost, cost-related medication nonadherence, overall worse physical health, clinical depression, and lower levels of emotional support (Table 1).

After multivariable logistic regression, women with premature ASCVD were more likely to report overall poor physical health (odds ratio [OR], 1.39; 95% CI, 1.09-1.78; P = .008), clinical depression (OR, 1.73; 95% CI, 1.41-2.14; P < .001), cost-related medication nonadherence (1.42; 95% CI, 1.11-1.82; P = .005), and inability to see a physician due to cost related issues (OR, 4.52; 95% CI, 2.24-9.13; P < .001) compared with men with premature ASCVD (Table 2). Directionally similar results were observed in the sensitivity analyses stratified by race and ethnicity and among adults with very premature ASCVD (eTable 2 in the Supplement).

Using data from a large nationally representative population, we found that women with premature ASCVD were more likely to report worse physical and general health and higher levels of clinical depression compared with their male counterparts. Despite having higher rates of health care coverage, women were more likely to have not seen a physician due to cost related concerns and to have cost-related medication nonadherence. These findings suggest that while women might be more likely to seek routine care, they may face barriers to accessing this care.

Prior studies have shown that despite having a significant number of cardiac risk factors, most young women may not believe that they are at risk of heart disease, such that they are less likely to discuss primary prevention strategies with their treating clinicians.¹¹ We found that despite having a primary care physician and health care coverage, women were more likely to have cost-related barriers to health care access. Women were also more likely to report lower income and to be below the federal poverty line. Thus, despite having health care coverage, it may be more difficult for women to see a clinician or take a prescribed medication compared with men because of copays or other expenses. With new therapies emerging, the cost of medication is expected to increase, which may worsen unaddressed disparities. Further, women have been shown to have higher rates of dissatisfaction with the health care system in the setting of poor patient-physician communication,¹² which may discourage them further from seeing their physicians.

Our study also indicates that women with established ASCVD were more likely to be clinically depressed and report worse overall physical health, general health, and lower levels of emotional support and satisfaction with life. Although not available for ascertainment in BRFSS, it is possible that this sex disparity among patients with ASCVD could be a reflection of the extra burden that young women with ASCVD carry in terms of caring for their families (children and parents) compared with men.^13,14 Addressing mental well-being as an integral part of management of ASCVD in young adults is of paramount importance. Clinicians should incorporate mental well-being screening in all visits for cardiovascular care, and families need to be supportive and dissuade patients with premature ASCVD from associating any stigma surrounding mental health issues. We believe that, apart from therapeutic inertia on the part of clinicians treating patients with premature ASCVD, social determinants also differentially impact women with premature ASCVD more often than men, further exaggerating these disparities in both receiving evidence-based therapies and adherence to those therapies.

We also report that, compared with the overall cohort, both men and women with premature ASCVD were more likely to report an inability to see a physician due to cost, cost-related medication nonadherence, overall worse physical health, clinical depression, and lower levels of emotional support (Table 1). Thus, adults with premature ASCVD in general constitute a vulnerable population. Our results aligns well with those of recent reports of higher cardiovascular mortality in socially vulnerable groups.¹⁵ These findings underscore the importance of narrowing cardiovascular disparities by encouraging policy-level efforts that advocate for integrating social determinants of health into existing clinical delivery support systems and promote investments in developing social risk assessment tools that enable physicians to specifically target this vulnerable population. Lastly, our results highlight the need for policy-level interventions to address out-of-pocket costs for this young patient population.

Our results must be interpreted in the context of certain limitations. This was a cross-sectional study, and therefore causality and directionality cannot be inferred. As information was self-reported, it is subject to measurement error and response bias. Whether poor physical and mental health was present before the diagnoses if ASCVD or developed as a result of ASCVD cannot be ascertained by our data. It is also noteworthy that participants with self-reported reduced health status may be selectively driving our findings, and our results could be reflective of this bias.

In conclusion, patients with premature ASCVD, especially women, are more likely to report worse overall physical and mental health, an inability to see a physician due to cost, and cost-related medical nonadherence. Interventions addressing mental health and out-of-pocket costs are needed in adults with premature ASCVD.

Accepted for Publication: November 9, 2021.

Published Online: January 5, 2022. doi:10.1001/jamacardio.2021.5430

Corresponding Author: Salim S. Virani, MD, PhD, Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030 (virani@bcm.edu).

Author Contributions: Dr Virani had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jain, Rifai, Turpin, Eken, Mahtta, Virani.

Acquisition, analysis, or interpretation of data: Jain, Rifai, Turpin, Agrawal, Samad, Coulter, Rodriguez, Petersen, Virani.

Drafting of the manuscript: Jain, Rifai, Turpin, Eken, Agrawal, Virani.

Critical revision of the manuscript for important intellectual content: Jain, Rifai, Turpin, Eken, Mahtta, Samad, Coulter, Rodriguez, Petersen, Virani.

Statistical analysis: Jain, Rifai, Turpin.

Administrative, technical, or material support: Coulter, Petersen.

Supervision: Mahtta, Petersen, Virani.

Conflict of Interest Disclosures: Dr Turpin was supported by the University of Maryland Prevention Research Center cooperative agreement from the Centers for Disease Control and Prevention. Dr Rodriguez was funded by a career development award from the National Heart, Lung, and Blood Institute and the American Heart Association/Robert Wood Johnson Harold Amos Medical Faculty Development Program. Dr Virani reported grants from the US Department of Veterans Affairs, World Heart Federation, Tahir, and Jooma Family Research Grant during the conduct of the study and other support from the American College of Cardiology Honorarium in his role as the Associate Editor for Innovations ACC.org outside the submitted work. No other disclosures were reported.