Comparative Assessment of Modifying Social Determinants to Reduce Cardiovascular Disease Burden and Disparities

项目摘要/摘要 尽管在预防和治疗心血管疾病(CVD)方面取得了进展，但财政紧张 迫使联邦和州政策制定者在相互竞争的政策决策之间做出艰难选择，通常 却没有有效的证据。比较有效性方法，或在缺乏实验的情况下 数据，一种比较评估方法，比较修改暴露的估计影响 使用观测数据，可以关键地为这种优先设置过程提供信息。我们和其他人已经证明 社会决定因素，如收入不平等和社会资本/凝聚力等上游社会因素 包括心血管疾病在内的疾病的关键预测因素。然而，重要的问题仍然是哪些社会决定因素 对心血管疾病负担的影响最大。此外，我们缺乏关于哪些亚群和 各州受到的影响最大。尽管呼吁进行比较评估/改进战略的有效性 人口健康和预防心血管疾病，包括来自国家卫生研究院的，我们仍然缺乏关于相对心血管疾病负担的知识 以及与修改这些因素相关的经济影响。有了这些信息，就有了关键的需求 准确估计社会决定因素对心血管疾病风险的影响；将这些估计转化为政策- 制定工具，包括对心血管疾病负担和成本的影响；以及比较和对比 这些影响。我们的总体目标是提供第一个比较评估证据基础，以 比较修改关键社会决定因素对中年人和老年人心血管疾病负担和经济影响的影响 年长的美国人。我们将通过利用数据实现以下具体目标来实现我们的总体目标 从两个具有全国代表性的中老年人大样本中，国家纵向 1979年青年调查(NLSY)和健康与退休研究(HRS)，与社会和经济有关 按居住地以及医疗保险索赔和死亡率数据库的衡量标准：目标1)以确定 哪些社会决定因素最能预测心血管疾病的发病率、死亡率和风险因素 在中老年人中；目标2)确定哪些亚群和地理状态 最容易受到社会决定因素对心血管疾病负担和风险因素的影响；以及目标3) 确定哪些社会决定因素如果被修改，预计将产生最大的减少 心血管疾病负担及其相关费用，包括总体和分群体。关于结果，我们的3- 一年的研究预计将确定最有希望的社会决定因素，在这些因素上进行干预以取得成果 成人心血管疾病负担的改善。我们将进一步确定地理和地理环境对脆弱性的影响 亚群可能解释了心血管疾病的差异。通过将我们的估计转化为人口健康和经济 措施，我们将直接响应在心血管疾病方面进行比较评估和经济评估的呼吁 预防研究。从长远来看，我们预计我们的项目将通过以下方式产生高度的翻译影响 指导政策制定者基于证据的决策，以减少心血管疾病负担和不平等。

PROJECT SUMMARY/ABSTRACT Despite advancements in prevention and treatments for cardiovascular diseases (CVD), fiscal constraints have driven federal and state policymakers to make difficult choices among competing policy decisions, often without evidence of effectiveness. A comparative effectiveness approach, or in the absence of experimental data, a comparative assessment approach that compares the estimated impacts of modifying exposures using observational data, can critically inform this priority-setting process. We and others have demonstrated that social determinants, upstream social factors such as income inequality and social capital/cohesion, are key predictors of disease including CVD. Yet important questions remain about which social determinants have the biggest impacts on CVD burden. Furthermore, we lack knowledge on which subpopulations and states are most affected. In spite of calls for comparative assessments/effectiveness of strategies to improve population health and prevent CVD, including from NIH, we still lack knowledge on the relative CVD burden and economic impacts associated with modifying such factors. Given this information, there are critical needs to accurately estimate the impacts of social determinants on CVD risks; to translate these estimates into policy- setting tools including impacts on CVD burden and costs; and to compare and contrast the costs and sizes of these impacts. Our overall objective is to provide the first comparative assessment evidence base to compare the CVD burden and economic impacts of modifying key social determinants in middle-aged and older Americans. We will accomplish our overall objective by pursuing the following specific aims using data from two large, nationally-representative samples of middle-aged and older adults, the National Longitudinal Survey of Youths 1979 (NLSY) and the Health and Retirement Study (HRS), linked to social and economic measures by area of residence, and to Medicare claims and mortality databases: Aim #1) To determine which social determinants most strongly predict the risks of CVD incidence, mortality, and risk factors in middle-aged and older adults; Aim #2) To identify which subpopulations and geographic states are most vulnerable to the influences of social determinants on CVD burden and risk factors; and Aim #3) To determine which social determinants if modified are expected to yield the greatest reductions in CVD burden and its associated costs, both overall and by subpopulation. Regarding outcomes, our 3- year study is expected to identify the most promising social determinants on which to intervene to yield improvements in adult CVD burden. We will further establish how vulnerabilities to effects by geography and subpopulations may explain CVD disparities. By translating our estimates into population health and economic measures, we will directly respond to calls for comparative assessments and economic evaluations in CVD prevention research. Over the long term, we expect that our project will have high translational impact through guiding policymakers' evidence-based decisions to reduce CVD burden and inequities.