Advisor(s)

Emily Levitan

Committee Member(s)

Kathryn Foti
Lonnie Hannon Iii
Madeline Sterling
Thomas Buford

Document Type

Dissertation

Date of Award

6-18-2026

Degree Name

Doctor of Philosophy (PhD)

School

School of Public Health

Department

Epidemiology

Abstract

STRUCTURAL AND LIFE-COURSE DETERMINANTS OF CARDIOVASCULAR DISEASE RECOVERY AND FUNCTIONAL INDEPENDENCE IN OLDER ADULTS ENE MERCY ENOGELA EPIDEMIOLOGY ABSTRACT Introduction: Among older adults recovering from cardiovascular events (e.g., myocardial infarction [MI], heart failure [HF]), there are wide disparities in recovery and independence by race and ethnicity that reflect the cumulative influence of social and structural conditions. While frailty and functional decline after hospitalization and decreases in mobility with age are common, little is known about how structural determinants of health shape post-discharge recovery and mobility. Objectives: This study examines (1) state-level structural determinants of health and post-discharge frailty after MI and HF in Medicare beneficiaries, (2) state-level structural determinants of health and cardiac rehabilitation utilization after MI in Medicare beneficiaries, and (3) the association of racial residential segregation over the life-course on life-space mobility in later life among the REasons for Geographic And Racial Differences in Stroke study (REGARDS) study participants. Methods: We conducted retrospective cohort studies of Medicare beneficiaries aged ≥ 66 years hospitalized for myocardial infarction (MI) or heart failure (HF) between 2010 – 2018, assessing 1-year post-discharge frailty and cardiac rehabilitation initiation by race/ethnicity. State-level race/ethnicity-specific socioeconomic indicators (poverty, education, homeownership, unemployment, segregation) were derived from the 2010 American Community Survey (aggregated from census tract to state) and linked using multivariable logistic regression models. Life-course analyses in the REGARDS study used residential history (1940 – 2010) to determine exposure to racial residential segregation and least angle regression (LARS) to identify data driven hypotheses linking segregation exposures across the life-course to life-space mobility in later life. Results: Among over 1.2 million Medicare beneficiaries, 54% of MI and 63% of HF patients had frailty at 1 year post-discharge. Only 14% of MI patients initiated cardiac rehabilitation within 1 year with lower rates among race/ethnic minority beneficiaries. State-level structural determinants of health were modestly associated with post-discharge frailty, and these associations varied across racial and ethnic groups. In REGARDS (n = 2885), cumulative, childhood and changing segregation exposures predicted poorer late-life life-space mobility, with stronger adverse effects among individuals reporting discrimination or low social support. Conclusion: While state-level factors had modest associations with post-discharge frailty and cardiac rehabilitation utilization, life-course exposures demonstrated stronger links with late-life mobility, suggesting the importance of considering cumulative social and environmental risk.

Keywords

Aging;Cardiac rehabilitation;Cardiovascular diseases;Frailty;Life-course;Structural determinant of health

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Available for download on Sunday, November 29, 2026

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