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Social Determinants of Health and Implicit Bias
Atrial Fibrillation: Optimizing Outcomes by Addressing Social Determinants of Health and Implicit Bias

Released: June 01, 2023

Expiration: June 01, 2024

Stephanie Jalaba
Stephanie Jalaba, MMS, PA-C
Kathleen A. Lusk
Kathleen A. Lusk, PharmD, BCPS, BCCP
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Key Takeaways
  • An important step in changing healthcare inequities in the management of atrial fibrillation (AF) involves healthcare professionals educating themselves about social determinants of health and how these may affect patients’ disease risk factors as well as diagnosis, management, and outcomes.
  • Implicit biases affect outcomes by affecting quality of care and patient–healthcare professional interactions.
  • Identifying the interplay between implicit biases and social determinants of health is crucial to make meaningful changes in diagnosing and treating AF.

Atrial fibrillation (AF) is the most common sustained arrhythmia diagnosed, and its prevalence is expected to double by 2030. Unfortunately, disparate outcomes in the management of cardiovascular disease (CVD), including AF, are consistently seen in racial and ethnic minorities. The rate of death from CVD remains 20% higher in Black Americans than in White Americans. Underdiagnosis and underuse of guideline-based therapies in minority populations with AF are contributing factors to the worse outcomes seen in these populations. 

A patient’s health is influenced by numerous factors, including social determinants of health (SDOH). SDOH are environmental circumstances into which individuals are born and where they live. SDOH include race, ethnicity, health literacy, financial resources, social support, neighborhood factors, and healthcare access. Healthcare professionals (HCPs) must understand and recognize SDOH because they affect patients’ risk factors, diagnosis, management, and outcomes. Addressing SDOH at each visit allows HCPs to identify patient barriers and determine how to provide care tailored to the patient’s individual circumstances.

Financial status is a key SDOH. Lower-income individuals often face barriers to accessing healthcare, medications, nutritious food, transportation, and safe housing, which negatively affect their health and quality of life. Individuals with fewer financial resources are more likely to develop chronic disease risk factors, which makes the prevention of diseases like AF increasingly difficult. In addition, lower socioeconomic status is linked with higher disease incidence and less optimal prescribing patterns. In the management of AF, anticoagulation prescribing is less than optimal in lower socioeconomic populations. 

Education and health literacy are also significant SDOH. Higher education levels are associated with better health outcomes, as they may provide the knowledge and skills to make healthier choices and access resources. Low health literacy is associated with worsened disease risk factors and health outcomes and increased healthcare utilization and costs. Approximately one third of the adult US population has limited health literacy. HCPs should assess patients’ health literacy before assuming that patients understand the context and education being provided to them. In addition, language barriers can limit patient care and should be addressed. 

Social support networks, including family, friends, and community, can have a positive impact on mental and physical health by helping individuals cope with stress, providing emotional support, and encouraging healthy behaviors. The physical environment in which a patient lives and works influences health in many ways. Factors such as air quality, access to green spaces, and neighborhood safety contribute to health and well-being. Several factors have been found to contribute to poorer health outcomes in rural communities, including increased risk factor burden, less access to healthcare, less patient education, and poorer health literacy. 

Improving SDOH involves addressing racial and ethnic disparities in care, promoting health literacy and education, improving living conditions and social support, and providing adequate healthcare resources. Policies and interventions by HCPs can contribute to this effort. Simple efforts such as an intake form to gather SDOH data may make a tremendous difference in the quality of patient care. 

HCPs can address health disparities by understanding how implicit biases affect their ability to recognize and address SDOH. Implicit biases are unconscious attitudes and stereotypes that affect behavior and decision-making. They can be based on factors such as race, ethnicity, gender, age, or socioeconomic status. Implicit biases can lead to misdiagnosis, inadequate treatment, poorer outcomes, and reduced trust in the healthcare system.

Implicit biases can exacerbate healthcare access disparities that stem from SDOH. HCPs must recognize that, as humans, we are inherently capable of having implicit biases, with no intent of harm. By exploring the intersection of SDOH and implicit biases, HCPs can identify ways to address these issues and create a more equitable healthcare landscape. Education, including cultural competency training, implicit bias training, and communication skills, is vital in mitigating the impact of implicit biases in healthcare. Annual implicit bias training is part of many state licensing requirements for HCPs and is woven into many medical education curricula. 

HCPs can direct treatment decisions with guideline-based and evidence-based processes rather than allowing biases to drive decisions. Augmentations may be appropriate to accommodate specific SDOH, such as prescribing a more affordable medication for a patient with financial barriers. This type of individualization in care may improve adherence to treatment and outcomes. Multidisciplinary care is another way to help reduce health disparities and bridge the gap for patients. HCPs can collaborate to help patients find connections for resources to combat identified health disparities (eg, finding coupons to assist with medication cost or finding ways to fund transportation to medical appointments).

SDOH and implicit biases interact in many ways, often exacerbating health disparities. The end result is less than optimal care and outcomes for our patients. As HCPs strive to advance equities in healthcare for all, efforts will need to be continued to educate on and address SDOH and implicit biases. This is especially true with AF, as we focus on minimizing the expected doubling of disease in our population by 2030 with prevention. Addressing SDOH and implicit biases may allow HCPs to better recognize and educate patients on the reversible risk factors for developing AF, many of which are affected by SDOH and bias. 

Your Thoughts?
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