Social Determinants and Inequalities in Health Care in Congenital Heart Disease

Doctor examining patient health on coronary artery disease, blood vessel or congenital heart defect, heart rhythm problem, arrhythmias, cardiovascular illness in medical clinic by checking heartbeat
The AHA has issued a scientific statement regarding lifelong social determinants of health and health disparities experienced by patients with congenital heart disease.

Among US patients with congenital heart disease, multiple inequalities exist in health care and need to be addressed at population, institutional, systemic workforce, and individual levels, according to a scientific statement published recently in the Journal of the American Heart Association.

Not long ago, the majority of infants diagnosed with congenital heart disease (CHD) died before their first birthday. Now, more than 97% of these children reach adulthood, and currently there are more adults living with CHD in the US than there are children with CHD in the US. Researchers sought to examine disparate health care access, inequities in overall CHD mortality and morbidity, and overall quality of health services in the context of varying social determinants of health, systemic inequities, and structural racism.

They noted that continued advancements are significantly influenced by inequitable treatment due to implicit bias based on an individual’s race or ethnicity, disparate outcomes based on systemic inequities and structural barriers differentially impacting patients because of systemic racism, and differences in economic and social determinants of health. Sex and geographic disparities are equally concerning.

Population-level approach is defined by accessibility, availability, and affordability. Although prenatal detection improves post-birth outcomes, accessibility shows less than 70% of patients with CHD in the US are diagnosed before birth, and low-income families are associated with lower prenatal detection.

Availability is defined by geography of the population and geography of health care professionals with transportation, especially for low-income families at issue. The increase in telehealth and satellite clinics could help even disparities.

Affordability in the US is defined by health care insurance, with poor insurance or lack of insurance raising significant barriers to health care equality.

Researchers also found that larger volume hospitals experienced less disparities than smaller volume hospitals, and believe this may be due to larger volume hospitals having more surgical experience and better postoperative intensive care. Smaller volume hospitals may not be so affected in economically enhanced locales.

In the health care workforce, communities with more minorities are significantly more likely to deal with physician shortages. Researchers noted that parents of patients with limited English proficiency had great improvements in quality of care when they had a bedside nurse that could speak their language.

On the individual level, racial and ethnic minority patients gave personal testimonies on the negative impact experienced discrimination has on health outcomes, access to care, and health care processes.

The researchers concluded, “There are multilevel contributors that continue to facilitate health inequities in the care of the patient with CHD in the United States. To mitigate these inequities, we must take a multipronged approach and examine contributors at the population, systemic, institutional, and individual levels.”


Lopez KN, Baker-Smith C, Flores G, et al. Addressing social determinants of health and mitigating health disparities across the lifespan in congenital heart disease: A scientific statement from the American Heart Association. J Am Heart Assoc. Published online April 7, 2022. doi:10.1161/JAHA.122.025358