Social Vulnerability Index and Cardiovascular Disease Care Continuum

Background Social vulnerability index (SVI) estimates the vulnerability of communities to disasters, encompassing 4 separate domains (socioeconomic, household composition and disability, minority status and language, and housing and transportation). The SVI has been linked with risk and outcomes of cardiovascular disease (CVD). Objectives This scoping review explored the literature between the SVI and CVD continuum, with a goal to identify gaps in understanding the impact of the SVI on CVD and to elucidate future research opportunities. Methods We systematically searched 7 databases from inception to May 19, 2023, for articles that explored the relationship between the SVI and CVD care continuum, including prevention, diagnosis and prevalence, treatment, and health outcomes. Extracted data included SVI ranking type, populations, outcomes, and quality of studies. Results Twelve studies evaluated the impact of SVI on the CVD continuum. Five studies explored mortality outcomes, 3 studies explored CVD risk factor prevalence, 4 studies explored CVD prevalence, 1 study explored access to health care in those with CVD, 1 study explored the use of cardiac rehabilitation services, and 1 study explored heart failure readmission rates, all of which revealed statistically significant associations with SVI. All studies included the SVI aggregate percentile ranking, while 5 studies focused on individual thematic components. We identified gaps in understanding the SVI's impact on CVD care continuum, particularly regarding CVD prevention and early detection. Conclusions This review provides a comprehensive understanding of the SVI's application in assessing various aspects of the CVD care continuum and highlights potential avenues for future research.

C ardiovascular disease (CVD) con- tinues to pose a major health challenge across the globe, with the United States being no exception.Nearly 50% of American adults experience CVD to varying extents 1 and CVD claims more lives than all types of cancer combined in the United States. 1 The burden of this disease is heterogenous, and socioeconomically deprived communities are disproportionately affected.A broad array of social determinants contributes to the onset and progression of CVD, creating a wide array of interlinked factors.These social determinants of health (SDOH) encompassing 6 key domains: economic stability, education, health care, neighborhood/built environment, community/social context, and food insecurity significantly influence prevalence and outcomes of CVD. 2 However, despite a heightened focus on longstanding health disparities in the United States, our understanding of the impact of SDOH on CVD remains limited and under-researched.
In an effort to dissect the mechanisms by which SDOH contributes to CVD, public health researchers have introduced a multidisciplinary approach.This involves a blend of epidemiological and translational research to reveal the relationships between SDOH and cardiovascular health.Within this focus of research lies the vital task of quantifying SDOH, a method of characterization that has recently taken center stage.Multiple metrics have been developed to quantify SDOH.This includes collection of objective data across distinct SDOH domains that may impact the health of an individual or community.4][5] In contrast to other available indices, the SVI offers granular data on 16 unique social variables at the county and census-level tracts under 4 themes including socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation.
Characteristics of these 4 themes are further described in Table 1.Social vulnerability refers to a community's potential susceptibility to adverse effects resulting from natural or human-induced disasters, as well as disease outbreaks.These communities, burdened by their vulnerability, frequently need additional assistance before, during, and after such events.The Agency for Toxic Substances and Disease Registry under the Centers for Disease Control and Prevention leverages the SVI to pinpoint these geographically vulnerable regions. 5cordingly, they can effectively identify the regions that require urgent aid and sustained support in the face of impending or ongoing disasters.
While the SVI was initially conceived to assist emergency response planners and public health officials in identifying communities requiring additional support, its application has extended in recent years.Researchers have begun to evaluate its impact across the entire spectrum of CVD care as a marker of global SDOH.The SVI has been found to significantly influence many stages of the CVD trajectory.][8][9][10][11][12][13] Thus, our study aimed to review the existing body of literature that investigates the correlation between the SVI and the continuum of CVD care.By describing the study populations, quality of the studies, and evaluating the use of the SVI, we aimed to identify gaps in the current understanding of the SVI impact on CVD care continuum and highlight potential avenues for future research.Reviews and Meta-Analyses) guidelines. 14The primary objective was to identify and map the emerging evidence of SVI's impact on the CVD care continuum, rather than to evaluate the feasibility or effectiveness of specific practices or treatments.Accordingly, we conducted the study using a scoping review approach, which is best suited to assess the breadth of a particular body of literature. 15IGIBILITY CRITERIA.Studies were deemed eligible for inclusion if they analyzed the impact of the SVI on the CVD care continuum, including observational and qualitative studies.Systematic reviews and metaanalyses may be included for evaluation of their reference lists.We excluded editorials, opinion pieces, and conference abstracts.In the full-text screening phase, studies were evaluated based on the inclusion/exclusion criteria.The majority of excluded studies were due to assessment of various SDOH measures that did not include the SVI, or the studies evaluated the impact of the SVI on outcomes unrelated to the CVD care continuum.
A total of 12 studies were ultimately selected for inclusion in our scoping review.Detailed summaries of these studies can be found in Table 2.

STUDY POPULATIONS AND OUTCOME MEASURES.
Our analysis encompassed a diverse range of study populations and outcome measures, providing a comprehensive view of the existing research landscape on the SVI in relation to CVD.In 5 of the selected studies, the primary objective was to evaluate the influence of the SVI on mortality outcomes related to CVD. 8,9,[17][18][19] Three studies probed the impact of the SVI on CVD risk factors. 6,7,10Four studies examined the association between the SVI and the prevalence of CVD. 7,9,10,12One study focused on the association between the SVI and access to health care in patients diagnosed with atherosclerotic CVD. 20One study explored the association between the SVI and the utilization of cardiac rehabilitation services. 21One study investigated the impact of the SVI on hospital readmission rates among patients who were recently discharged following an episode of acutely decompensated heart failure. 11Overall, these studies provide a multifaceted perspective on how the SVI can influence different aspects of the CVD care continuum (Figure 2).
UTILIZED DATA SOURCES.Within the included studies, there was a broad spectrum of data sources used, ranging from publicly accessible data repositories to institutional records and survey data.

Two studies relied on the Behavioral Risk Factor
Surveillance System database to procure data on CVD risk factor prevalence and coronary heart disease prevalence. 7,10Another study made use of data from the 2010 American Community Survey to establish urban-rural classifications, allowing for a stratified Social Vulnerability and Cardiovascular Disease analysis of their results. 78][19] Three studies utilized the Behavioral Risk Factor Surveillance System database to obtain a wealth of demographic information and other SDOH. 10,20,21These data included patient age, race/ ethnicity, employment status, educational status, tobacco use, income level, and indicators of health care access.Institutional data records provided a direct and detailed source of patient information in 2 studies. 11,12One study leveraged the American Heart Association COVID-19 CVD Registry to inform their analysis. 9Lastly, another study conducted a secondary analysis of the InterGEN Study to secure patient information relevant to their objectives. 6E OF THE SVI.SVI data are available at both the census-tract and county level, as each residential address in the United States is linked with a unique 15-digit geographic identifier which includes a state code, county code, census tract code, and, where relevant, a census block code.This enables patient data to be tied with specific SVI data, providing a clear geographical context for the analysis.Census tracts, as aggregates of county subdivisions, were utilized as the unit of SVI data in 4 of the studies. 6,7,12,21One of these studies further leveraged the census-tract level data to ascertain neighborhood vulnerability. 6][10][11][12][17][18][19][20][21] Five of these studies went further by analyzing the individual SVI themes to determine their specific impacts on CVD. 6,7,9,10,18garding the interpretation of SVI rankings, 6 1 Seven studies treated the SVI as a continuous variable, [6][7][8]11,12,19,21 while 1 study used the SVI as a categorical variable without subdividing its overall percentile rankings into quartiles or tertiles.6 ASSOCIATIONS BETWEEN SVI AND CVD.In all 12 studies, greater SVI was statistically associated with multiple components of the CVD continuum. This incuded increased premature cardiovascular death, 18 higher likelihood of dying from heart failure at home or an inpatient facility compared to nursing homes, 19 decreased access to cardiac rehabilitation and health care access, 20,21 increased CVD risk and coronary heart disease prevalence, 6,7,10 higher odds of myocardial fibrosis on autopsy, 12 higher cardiooncology-related death, 8 and poor outcomes including readmissions and mortality.9,11,17 STUDY QUALITY. All included stdies were appraised through utilization of the STROBE checklist.The score ranged from 0 to 22 based on the number of included items.The majority of our studies completed all items on this checklist with a score of 22. [7][8][9][10]12,18,21 Two studies scored 20 6,19 , 1 study scored 19, 11 and 2 studies scored 18. 17 Social vulnerability focuses on a comprehensive approach to measure social circumstances in communities in the United States that differs in many ways from SDOH (conditions related to where people are born, live, age, and work) and socioeconomic status (social status, income, education).24][25][26] Chronic conditions were also found to be more frequent in populations with a higher SVI, which include depression and anxiety, CVD, and obesity.27 Given that aspects of life control and social engagement are quantified in the SVI, these populations are expected to have higher rates of smoking, physical inactivity, heavy drinking, and limited access to health care and healthy foods.[28][29][30] These unique characteristics of the SVI support its use when evaluating social aspects of cardiovascular care in the United States.
One of the key goals of our study was to identify the knowledge gaps regarding the impact of social vulnerability on the CVD care continuum (Figure 3).
Among the 12 identified studies, there was a lack of emphasis on the influence of SVI on prevention and  STUDY LIMITATIONS.Our study is not without limitations.Given the population-level design of the included studies, these findings are unlikely to be exclusively applicable to individual-level data.Our preliminary exploration of the topic revealed potentially relevant literature that would not get captured with searching of records in databases but had the pertinent information in the full text.While we made an effort to search resources that provide full-text searching, it is possible that studies were missed relating to this factor.Additionally, studies that evaluated the impact of SVI on populations who were not diagnosed or at risk of CVD were excluded; however, studies may have been inadvertently excluded from this analysis if they were not explicitly identified during the screening process.Lastly, studies with statistically significant findings are more likely to be published; hence, publication bias remains a possibility.

CONCLUSIONS
Our scoping review explored the relationship between the SVI and the continuum of CVD care.The SVI has been evaluated for its impact on mortality outcomes, CVD risk factors, disease prevalence, access to health care, utilization of cardiac rehabilitation services, and hospital readmission rates, demonstrating the versatile use of the SVI as a comprehensive metric of social vulnerability.Gaps in understanding the impact of SVI were identified, primarily among CVD prevention, early detection, and effectiveness of treatment options.

FUNDING SUPPORT AND AUTHOR DISCLOSURES
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

A
B B R E V I A T I O N S A N D A C R O N Y M S CVD = cardiovascular disease SDOH = social determinants of health SVI = social vulnerability index METHODS Our review was completed in accordance with the PRISMA (Preferred Reporting Items for Systematic

RESULTSFigure 1
Figure 1 depicts the flow of records from the search yield through the study selection process.The initial search yielded a total of 1,812 records from which 465 duplicates were identified leaving the number of records available for study selection to be 1,347.After completing the title/abstract screening of records for relevance, 1,263 records were excluded, and 84 records moved forward to the full-text screening phase.
while 1 study utilized SVI data at the zip code level. 11The SVI offers a comprehensive ranking for each geographical region, comprising 16 social factors grouped under 4 themes: household characteristics, socioeconomic status, racial and ethnic minority status, and housing type and transportation.These themes, individually and collectively, are assigned percentile rankings from 0 to 1 to indicate the level of social vulnerability, with 0 representing the least vulnerable and 1 the most vulnerable.Studies can assess the impact of SVI on CVD using either the aggregate SVI ranking, encompassing all 4 themes, or by focusing on individual themes.All 12 studies employed the overall SVI aggregate percentile

FIGURE 2 4 Social
FIGURE 2 Evaluation of SVI in the CVD Care Continuum

, 20 DISCUSSION
In this scoping review, we comprehensively explored the current body of literature examining the relationship between the SVI and the CVD care continuum (Central Illustration).We demonstrate the versatile utility of the SVI in examining various facets of CVD, from risk factors and prevalence to health care access and outcomes, including mortality.The ways in which the SVI was employed also varied, with all studies using the aggregate index and a few of which investigated the individual thematic components.This provided a multidimensional perspective on the role social vulnerability plays in CVD care.
CENTRAL ILLUSTRATION Social Vulnerability Index and Cardiovascular Disease Care Continuum: A Scoping Review Ibrahim R, et al.JACC Adv.2024;3(7):100858.early detection of CVD, including accessibility and effectiveness of preventive screenings and early detection initiatives.There was also a lack of understanding regarding the effectiveness of specific treatments or interventions for CVD.Complementing SVI, an exploration of patient-level SDOH and their interaction with SVI might enrich our understanding of individual health outcomes.This also includes investigating the linkage between SVI and individualpatient awareness of CVD.Furthermore, most included studies are based on cross-sectional analyses, suggesting the need for longitudinal studies that investigate how changes in SVI, or counties among varying SVI rankings, impact CVD outcomes over time.Lastly, given the profound impact of the SVI on CVD care continuum, further investigation into the impact of the SVI on health care policies and how these policies influence SVI-related CVD disparities would be warranted.These findings aim to empower population-health researchers to identify these missing components of SVI in CVD care continuum.Additionally, with rapid advancements of machine learning and artificial intelligence technologies, there exists unprecedented opportunities to integrate the SVI into large population-health and electronic medical record databases.With the use of geocoding applications, this would allow epidemiologists and researchers to analyze the spatial distribution of the SVI components alongside clinical health records, paving the way for development of polysocial risk scoring systems.These scores would be instrumental in targeting the multifaceted nature of health risks faced by individuals.The impact of SDOH on cardiovascular outcomes is poorly understood as a result of the inadequate attention to socially vulnerable groups.Furthermore, this is complicated by contemporary reimbursement models that mitigate the need to document and use SDOH in clinical decision-making, time and resources promoting collection of SDOH data in real-world databases, and lack of application of quantitative analytic methods to assess the impact of SDOH on a population scale.31SDOH definitions consider a range of conditions in the environments where people are born, live, and socialize, acknowledging their potential effects on health and life quality.However, these definitions may not adequately capture critical social factors like discrimination, stigma, and marginalization.Elements such as ethnic residential segregation, the quality of neighborhood infrastructure, accessibility to small grocery outlets, personal perceptions of safety, job-related stress, and feelings of loneliness or

FIGURE 3 4 Social
FIGURE 3 Gaps in Understanding Regarding the Impact of SVI on CVD Care Continuum

:TRANSLATIONAL OUTLOOK 2 :
Dr Ramzi Ibrahim, Department of Medicine, University of Arizona-Tucson, UA College of Medicine, 6th Floor, Room 6336, 1501 North.Campbell Avenue, Tucson, Arizona 85724, USA.E-mail: ramzi.ibrahim83@gmail.com.PERSPECTIVES COMPETENCY IN PATIENT CARE: The social vulnerability index has been shown to influence many different stages of the cardiovascular disease trajectory, emphasizing the importance of considering social determinants when managing these patients.TRANSLATIONAL OUTLOOK 1: A diverse array of populations, outcome measures, data sources, and applications of the social vulnerability index were seen, emphasizing the versatile utility of the social vulnerability index in examining the multifaceted nature of the cardiovascular disease care continuum.Gaps in knowledge regarding the impact of the social vulnerability index on cardiovascular disease care continuum exist, primarily related to prevention, early detection, and effectiveness of treatment modalities, highlighting potential avenues for research.

TABLE 1
Characterization of the Social Vulnerability Index Native Hawaiian and other Pacific Islander, not Hispanic or Latino Multiunit structures 2 or more races, not Hispanic or Latino Other races, not Hispanic or Latino Four underlying themes and 16 components of the social vulnerability index.

TABLE 2
Strengthening the Reporting of Observational Studies in Epidemiology; SVI ¼ social vulnerability index.
20 County-Level Social Vulnerability is Associated With In-Hospital Death and Major Adverse Cardiovascular Events in Patients Hospitalized With COVID-19: An Analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry 2018 SVI release Cross-sectional design Does the SVI have an impact on in-hospital outcomes in those with COVID-19?County-level rates of in-hospital all-cause mortality and major adverse cardiovascular events in relation to COVID-19 CVD ¼ cardiovascular disease; PCP ¼ primary care physician; STROBE ¼