Date of Award
Spring 2023
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Public Health
First Advisor
Lichtman, Judith
Abstract
Perceived discrimination, defined as experiences of indignities, microaggressions, and other types of mistreatments that privileged groups enact towards members of disadvantaged groups, is a chronic stressor that has been shown to be associated with risk factors for cardiovascular disease and incident cardiovascular events. Previous studies have hypothesized that perceived discrimination adversely affects cardiovascular health through multiple physiological, behavioral, and psychosocial pathways. However, the impact of perceived discrimination on outcomes and healthcare utilization among young adults (age 18 – 55 years) hospitalized for acute myocardial infarction (AMI) is largely unknown. This work leveraged data from the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) to evaluate the associations of perceived discrimination with disease-specific health status outcomes, outpatient care utilization, and biomarker outcomes during the first 12-months following hospitalization for AMI among young adults in the United States. In Aim 1, we analyzed the 1- and 12-month disease-specific health status of 2,670 young adults enrolled in the VIRGO study. Disease-specific health status was measured using the Seattle Angina Questionnaire (SAQ), which was designed to be used for patients with coronary artery disease and includes the following domains: physical limitations, angina frequency, angina stability, treatment satisfaction, and quality of life. Specifically, it quantifies patients’ symptoms of angina and the extent to which their angina affects their day-to-day functioning. Perceived discrimination was assessed using the Everyday Discrimination Scale (EDS). Good to excellent disease-specific health was defined as a SAQ Summary Score ≥ 75 and being angina-free was defined as a SAQ Angina Frequency score of 100. Treatment satisfaction (TS) was measured using the TS domain score of the SAQ. Multivariable linear regression of the TS domain score and multivariable logistic regression of dichotomous forms of the SAQ Summary Score and being angina-free were used to assess their adjusted associations with perceived discrimination. We found that higher level of perceived discrimination was associated with lower odds of having good-to-excellent health status and being angina free, as well as worse treatment satisfaction at both 1- and 12-months post-AMI. Further, the inverse association between perceived discrimination and treatment satisfaction was stronger among Black participants compared to White participants. These findings demonstrate that perceived discrimination is associated with disease-specific health status outcomes after adjustment for potential confounders and should be considered when treating young adults with AMI. Receiving timely follow-up care is an important aspect of AMI recovery. In Aim 2, we used multivariable logistic regression to assess the association between perceived discrimination and the odds of receiving a guideline-recommended outpatient follow-up visit with a primary care or cardiac provider within 1-month of discharge. We also used negative binomial regression of the total number of outpatient visits during the first 12-months after AMI hospitalization to assess its association with perceived discrimination. We found that there was no association between perceived discrimination and having an outpatient visit with a primary care or cardiac provider at 1-month post-AMI. However, a higher level of perceived discrimination was associated with lower total number of outpatient visits during the first 12-months following AMI hospitalization among Black participants. The impact of structural racism on access to health-promoting resources as well as medical mistrust among Black individuals due to historic mistreatment by the medical field may serve as barriers to accessing outpatient care in the post-AMI period. Perceived discrimination has also been shown to be associated with dysregulation of physiological processes such as neuroendocrine and metabolic pathways involved in the stress response. Therefore, in Aim 3, we used multivariable linear regression to assess the associations between perceived discrimination and log-transformed concentrations of inflammatory markers (high-sensitivity C-reactive protein and lipoprotein-association phospholipase A2) and serum lipids (total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides) at 1-month post-AMI. We found counter-intuitive inverse associations between perceived discrimination and inflammatory markers and no association with serum lipids in fully adjusted models. Future work in more racially diverse samples that measure important mediators of the impact of chronic stress on biomarker outcomes such as coping behaviors and internalized biases is needed. In this dissertation, we demonstrated the negative impact of perceived discrimination on post-AMI health status outcomes among young adults. Importantly, we are the first to evaluate the associations of perceived discrimination with outpatient care utilization and biomarker outcomes following hospitalization for AMI. Finally, we leveraged our findings to identify potential targets for individual- and system-level interventions to mitigate exposure to discrimination in the healthcare setting and improve post-AMI outcomes among young adults who experience discrimination in their everyday lives.
Recommended Citation
Arakaki, Andrew, "Evaluating the Impact of Perceived Discrimination on Patient-Reported Outcomes, Outpatient Care Utilization, Inflammatory Markers, and Lipid Profiles in Young Adults Hospitalized for Acute Myocardial Infarction (AMI)" (2023). Yale Graduate School of Arts and Sciences Dissertations. 952.
https://elischolar.library.yale.edu/gsas_dissertations/952
