Leaving the Social Vacuum: Expanding Cardiovascular Guidelines to Embrace Equity.
Leaving the Social Vacuum: Expanding Cardiovascular Guidelines to Embrace Equity.
复制标题
离开社会真空：扩大心血管指南以拥抱公平。
DOI：
10.1161/circulationaha.122.060881
复制
发表时间：
2022-07-19
期刊：
影响因子：
37.8
通讯作者：
Brewer LC
中科院分区：
文献类型：
--
作者：
Magnani JW;Brewer LC
心脏病学院/美国心力衰竭学会心力衰竭管理指南2标志着我们所知的第一次发生，即社会决定因素在基于指南的护理中被明确优先考虑。因此，准则一般都忽略了妨碍其公平执行的一系列复杂的社会因素，简而言之，准则是在社会真空中制定的。相反，心力衰竭（HF）指南承认社会因素对疾病管理的贡献。虽然HF指南主张更广泛的当代视角，但我们关注他们如何解决社会劣势，直接护理弱势患者人群，以及如何实现健康素养。我们的考虑是，HF指南是将健康的社会决定因素纳入专业协会指南的第一步。然而，正如这里所概述的和附表中所总结的，我们的期望是，他们可以做更多的事情来摆脱他们的社会真空，拥抱健康公平。HF指南的一个明确治疗原则是多药治疗，即鉴于联合治疗对HF结局的已证实获益，开具多种药物的处方。我们的论点并不在于该方法的证据，而在于假定它是现实的和可以实现的。长期医疗保健和自付费用与住房、食品安全、儿童保育和交通等日常财务负担竞争。资不抵债及贫穷在我们的社会中普遍存在，并因COVID-19疫情而加剧。我们最近作为合著者参与了一项工作，该工作证明了家庭收入和共同负担对HF药物沙库巴曲/缬沙坦的获得和依从性的影响。3 HF指南提出的解决财务障碍的主要方法是召集一个多学科团队。我们认为，假定这些资源是广泛存在的，特别是在社会处境不利的病人可能使用的卫生保健系统中，这是一种假定。对于心血管疾病指南，以促进健康公平，他们必须更明确地解决我们的证据和他们的可负担性之间的不协调，我们主张HF指南承认和解决真实的财务障碍，在其提供的护理范围内的药物和治疗。我们建议指南（1）为改善纵向可及性和公平性的成功项目提供循证路线图，（2）将理解患者的财务资源作为以患者为中心的护理的优先事项，通过简单的任务来证明，如运行测试脚本，向患者报告共付额，并与他们合作，开出他们负担得起的药物，以及（3）包括那些具有多学科专业知识的人作为指南编写委员会的一部分，如社会工作者和社会流行病学家，他们具有测量，评估和解决财务障碍的专业知识。社会经济上处于不利地位的患者不能让临床医生放弃对经济和社会现实对其生活和医疗保健经历的原始影响的理解。心血管指南在很大程度上是假设而不是明确的沟通过程和标准。相比之下，HF指南对健康素养的强调值得称赞，特别是
College of Cardiology/Heart Failure Society of America Guideline for the Management of Heart Failure2 marks the first occurrence to our knowledge that social determinants have been explicitly prioritized in guideline-based care. Heretofore, guidelines generally ignored the complex array of social factors that obstruct their equitable implementation and have been constructed, in short, in a social vacuum. In contrast, the heart failure (HF) guidelines acknowledge the contributions of social factors on disease management. Although the HF guidelines assert a broader, contemporary perspective, we have concerns about how they address social disadvantage, direct care in vulnerable patient populations, and approach health literacy. Our consideration is that the HF guidelines are a first step toward integrating social determinants of health into professional society guidelines. However, as outlined here and summarized in the accompanying Table, our expectation is that they can do more to depart from their social vacuum and embrace health equity. A clear treatment principle of the HF guidelines is polypharmacy, the prescribing of multiple medications given the demonstrated benefit of combination therapies for outcomes in HF. Our argument is not with the evidence of the approach, but with the presumption that it is realistic and achievable. Long-term health care and copays compete with mundane financial burdens, such as housing, food security, child care, and transportation. Financial insolvency and poverty are common in our society and have been exacerbated by the COVID-19 pandemic. We recently participated as coauthors in work that demonstrated the effect of household income and copayments on access and adherence to the HF medication sacubitril/valsartan. 3 The primary solution to financial barriers proposed by the HF guidelines is to call in a multidisciplinary team. We consider it presumptive to assume that such resources are widely available, particularly in the health care systems that patients living in socially disadvantaged conditions are likely to use. For cardiovascular disease guidelines to promote health equity, they must more explicitly address the dissonance between the treatments promoted by our evidence and their affordability.We would advocate that the HF guidelines acknowledge and address the real financial barriers to medication and treatment within their scope of the provision of care. We suggest that guidelines (1) present evidencebased roadmaps for successful programs that improve longitudinal access and equity,(2) situate understanding patients’ financial resources as a priority to patient-centered care, demonstrated by straightforward tasks such as running test scripts, reporting copays to patients, and working with them to prescribe the medications that they can afford, and (3) include those with multidisciplinary expertise as part of guideline writing committees, such as social workers and social epidemiologists, who have the expertise to measure, assess, and address financial obstacles. Patients who are disadvantaged socioeconomically cannot afford for clinicians to abdicate understanding of the raw effects of financial and social realities on their lives and medical care experiences. Cardiovascular guidelines have largely presumed rather than articulated processes and standards for communication. In contrast, the HF guidelines’ emphasis on health literacy is commendable, particularly as