A County-Level Index for Cardiovascular Mortality Based on Social Determinants to Identify High-Risk Areas in the United States
By
Anqi Zhu
Bibhas Chakraborty
Tazeen H. Jafar
December 2, 2025
Clinical Scorecard: A County-Level Index for Cardiovascular Mortality Based on Social Determinants to Identify High-Risk Areas in the United States
At a Glance
Category Detail
Condition Cardiovascular Disease (CVD) Key Mechanisms Social determinants of health (SDOH) influence health behaviors and long-term health outcomes. Target Population Residents of U.S. counties, particularly in high-risk regions. Care Setting Public health agencies and community-level interventions.
Key Highlights
CVD is the leading cause of death in the USA with significant geographic disparities. County-level SDOH account for nearly 75% of the variation in CVD mortality. A new Social Cardiovascular Mortality Index (SCMI) was developed using machine learning. SCMI aims to identify counties at high risk for CVD mortality. The study emphasizes the need for targeted public health interventions. Guideline-Based Recommendations
Diagnosis
Utilize county-level SDOH data to assess cardiovascular risk. Management
Implement community-level interventions based on SCMI findings. Monitoring & Follow-up
Regularly update SCMI with new public health data to track CVD mortality trends. Risks
Consider socioeconomic factors such as income and education when evaluating CVD risk. Patient & Prescribing Data
Individuals residing in U.S. counties with high CVD mortality risk.
Focus on addressing SDOH to improve cardiovascular health outcomes.
Clinical Best Practices
Incorporate SDOH assessments in cardiovascular health evaluations. Engage community stakeholders in developing targeted interventions. Utilize machine learning tools for predictive modeling in public health. References
