Clinical InvestigationOutcomes, Health Policy, and Managed CareAdding socioeconomic status to Framingham scoring to reduce disparities in coronary risk assessment
Section snippets
Samples
ARIC, our derivation sample, is an ongoing, prospective epidemiologic study conducted in 4 US communities. It was designed to examine the etiology and natural history of atherosclerosis and related diseases by race, sex, and location.8 The ARIC cohort component was initiated in 1987. Each ARIC field center randomly selected and recruited a sample of approximately 4,000 individuals aged 45 to 64 years from a defined population in 1 of 4 communities. Participants received extensive examination,
Results
There were 15,732 men and women included in ARIC. We excluded 2,324 (15%) subjects with prevalent CHD or diabetes (considered a CHD equivalent with >20% risk of CHD4) at baseline, leaving 13,408 persons. Next, we excluded 103 (<1%) subjects who were missing information needed to calculate the FRS and 743 (5%) subjects who were missing SES information (primarily income), leaving 12,562 subjects available for analysis. Based on the categories used, 26% of the eligible sample was in the lower-SES
Discussion
These findings demonstrate that standard FRS underestimates CHD risk for lower-SES US adults whether assessed by CHD events or CHD deaths. National Cholesterol Education Program guidelines for cholesterol treatment recommend FRS for those at intermediate risk.4 Application of these guidelines likely results in undertreatment, including use of behavioral and pharmacologic interventions, for those at lower SES due to poor calibration of FRS for this population.
Notably, we found that bias in CHD
Acknowledgements
Sean Meldrum, MS, who died unexpectedly before submission, conducted many of the analysis. There were no other contributors besides the named authors.
References (39)
- et al.
Differences between respondents and nonrespondents in a multicenter community-based study vary by gender ethnicity. The Atherosclerosis Risk in Communities (ARIC) Study Investigators
J Clin Epidemiol
(1996) - et al.
Coronary heart disease risk prediction in the Atherosclerosis Risk in Communities (ARIC) study
J Clin Epidemiol
(2003) - et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study
Lancet
(2004) - et al.
Randomized trial of a clinic-based, community-supported, lifestyle intervention to improve physical activity and diet: the North Carolina enhanced WISEWOMAN project
Prev Med
(2008) - et al.
Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study
Lancet
(2004) - et al.
Should years of schooling be used to guide treatment of coronary risk factors?
Ann Fam Med
(2004) - et al.
Socioeconomic factors and cardiovascular disease: a review of the literature
Circulation
(1993) - et al.
Comparison of the prediction by 27 different factors of coronary heart disease and death in men and women of the Scottish Heart Health Study: cohort study
BMJ
(1997) Executive summary of the third report of the National Cholesterol Education Program (NCEP)
JAMA
(2001)- et al.
Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation
JAMA
(2001)
Socioeconomic status and coronary heart disease risk prediction
JAMA
The accuracy of the Framingham risk-score in different socioeconomic groups: a prospective study
Br J Gen Pract
The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives
Am J Epidemiol
Sample design: Third National Health and Nutrition Examination Survey
Vital Health Stat
The Third National Health and Nutrition Examination Survey (NHANES III 1988-94) reference manuals and reports [CD-rom]
Poverty thresholds
Test of the National Death Index
Am J Epidemiol
An evaluation of the Social Security Administration master beneficiary record file and the National Death Index in the ascertainment of vital status
Am J Public Health
The accuracy of the National Death Index when personal identifiers other than Social Security number are used
Am J Public Health
Cited by (85)
Socioeconomic status and risk of in-hospital cardiac arrest
2022, ResuscitationSocioeconomic Deprivation and Premature Cardiovascular Mortality in the United States
2022, Mayo Clinic ProceedingsPatient-centric characterization of multimorbidity trajectories in patients with severe mental illnesses: A temporal bipartite network modeling approach
2022, Journal of Biomedical Informatics