Why We Need to Know Patients’ Education
Invited Commentary
Why We Need to Know Patients’ Education
Nancy E. Adler, PhD; M. Maria Glymour, ScD
Kubota and colleagues1 have further strengthened the litera-
ture linking education to risk of cardiovascular disease (CVD).
Using a large longitudinal community-based sample of African
American and white men and women with careful outcome
adjudication, they report
significant associations be-
Related article tween educational attain-
ment and lifetime risk of CVD.
The chance of incident CVD by age 85 years was 47% for 45-year-
old male high school graduates vs 55% for men without high
school credentials, nearly an 8–percentage point advantage. The
advantage of a high school diploma was even larger for women:
15 percentage points. These associations were graded, and the
gap between the highest (graduate/professional school) and low-
est (grade school) education groups was 17 and 23 percentage
points in men and women, respectively. Associations between
education and CVD were seen for both African Americans and
whites, although they were smaller for African American men
and women than for their white counterparts.
This new evidence supports adding education to the list
of high-priority CVD risk factors. The increased burden of CVD
associated with low education is comparable to that of other
major risk factors, but it is not routinely collected in clinical
settings and is often omitted from summaries of major car-
diovascular risk factors. The risk contribution of low educa-
tion may be overlooked because it operates outside the health
care system and is not under physicians’ control. In addition,
because schooling is usually completed many years before a
person develops CVD, the contribution of educational achieve-
ment to its onset or progression may be less salient than more
proximal risk factors such as health behaviors, chronic dis-
ease management, and acute medical care. We argue, how-
ever, that there is additional clinical value to assessing a pa-
tient’s educational level.
Clinical Care
Knowing patients’ educational levels can improve clinical de-
cision making and enhance the predictive accuracy of stan-
dard models, such as Framingham-based algorithms or the Eu-
ropean Systematic Coronary Risk Evaluation (SCORE) index.2
These and similar models inform treatment decisions based
on a patient’s underlying risk of adverse outcomes. For ex-
ample, anticoagulants are appropriate only when the risk of
ischemic stroke outweighs the possible increase in hemor-
rhagic risk induced by the medications. Failure to include edu-
cation—or other social risk factors—in predictive models can
underestimate the ischemic stroke risk faced by patients with
low education. Underestimation could affect decisions regard-
ing use of anticoagulants, leading to undertreatment of high-
risk patients with less education.
With many epidemiologic studies such as that by Kubota
et al,1 confounding can be an issue. The association of educa-
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Invited Commentary
tion with CVD risk could be attributable, at least in part, to fac-
tors linked to both educational attainment and to CVD risk. For
example, conscientious individuals may be more likely both
to complete their education and to follow recommended medi-
cal regimens. However, even if education is not directly causal,
but instead a summary marker for other unmeasured risk fac-
tors, it can increase the accuracy of predictive models.
Several studies have evaluated the impact of incorporat-
ing social determinants into predictive models (eg, Fiscella et
al3). Findings suggest that the added contribution is modest,
but still valuable, and even small improvements in the over-
all prediction model may reduce health disparities by increas-
ing the likelihood of appropriate care for the subgroup of pa-
tients who are most socially vulnerable.
Including information on patients’ educational levels could
also strengthen findings from data mining, including analy-
ses to support precision medicine. Big data, spanning mul-
tiple levels from the genome through other “omics,” fre-
quently lacks higher-level data on behavior and social and
physical environments, leading to analyses with exclusively
biological variables. Education may directly influence dis-
ease risk and/or moderate the impact of other variables. These
possibilities can only be evaluated if education and other so-
cial determinants are included in the data sets.
Progress in including this information has been slow be-
cause it is not systematically or routinely collected on pa-
tients, and no standard process exists for incorporating such
data into health records. To address this obstacle, the Na-
tional Academy of Medicine Committee on Capturing Social
and Behavioral Domains and Measures in Electronic Health
Records (2014) recommended a concise set of measures of
“psychosocial vital signs,” including educational attainment,
for inclusion in all electronic health records. The committee
recommended assessing the number of years of schooling com-
pleted and highest degree earned.4 The resulting informa-
tion could be used by clinicians in determining treatment, by
health systems in efforts to manage the health of patient pan-
els, and by researchers evaluating disease determinants.
Population Health Management
Health care payment reforms that incentivize clinicians to
keep their patients healthy are prompting clinicians and
health systems to focus more attention on prevention and
chronic disease management.5 This is occurring in the con-
text of a growing literature on the health effects of patients’
experiences outside clinic walls. Health systems are using
community benefit funds and other approaches to create
healthier conditions for the populations they serve. The
article by Kubota et al1 underlines the importance of improv-
ing educational outcomes and points to the need for
research about approaches that will have the greatest return
to improved health.
(Reprinted) JAMA Internal Medicine Published online June 12, 2017 E1
 Invited Commentary Why We Need to Know Patients’ Education

Leveraging education policy and interventions to reduce CVD
will require more specific information about their effectiveness,
cost, and time frame for seeing health effects. Investments early
in life can influence later outcomes; experimental studies have
shown, for example, that early childhood schooling initiatives
improve adult CVD risk factors, including hypertension.6 Health
systems may hesitate to invest for such long-term payoffs, how-
ever, and different incentives may be needed, informed by
empirical evidence on the relative health benefits of specified
investments in early childhood education, primary and second-
ary schooling, college, and adult education. We also need to ana-
lyze the role of school quality and its impact on health. Many older
African Americans in the cohort studied by Kubota et al1 would
have attended schools of lower quality than their white counter-
parts. Differences in school quality may contribute to the higher
rates of CVD and smaller returns on education often observed
in African American populations.
Health Care Policy
Evidence of the powerful health effects of social and behav-
ioral factors reminds us that health care policy is only one com-
ponent of health policy. The latter encompasses wider inputs
to health, including education, economic, and labor policy.
While education is foundational, mechanisms that mediate the
impact of education on CVD, such as financial security, behav-
ioral patterns, or psychosocial stressors, can constitute new
policy targets. A comprehensive approach can help avoid
wasted resources on irrelevant policies, and improve out-
comes for middle-aged and older patients whose schooling is
completed.
Finally, the evidence on the impact of social determi-
nants of health highlights an unintended consequence of our
current health care system, which in 2015 absorbed 18% of the
US gross domestic product. Health care payments impose a
steep opportunity cost: every dollar we spend on unneces-
sary tests, treatments, or procedures is a dollar we cannot in-
vest in other strategies, such as education, to improve health.
This trade-off adds urgency to efforts to provide greater value
in health care and control health care costs. The findings from
the study by Kubota et al1 provide further indication that in-
corporating social determinants may well deliver more “bang
for the buck” from our investments in health.

ARTICLE INFORMATION
Author Affiliations: Department of Psychiatry,
Center for Health and Community, University of
California, San Francisco (Adler); Department of
Pediatrics, Center for Health and Community,
University of California, San Francisco (Adler);
Department of Epidemiology and Biostatistics,
University of California, San Francisco (Glymour).
Corresponding Author: Nancy E. Adler, PhD,
Departments of Psychiatry and Pediatrics, Center
for Health and Community, University of California,
San Francisco, 3333 California St, San Francisco, CA
94143-0848 (nancy.adler@ucsf.edu).
Published Online: June 12, 2017.
doi:10.1001/jamainternmed.2017.1892
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Kubota Y, Heiss G, MacLehose RF, Roetker NS,
Folsom AR. Association of educational attainment
with lifetime risk of cardiovascular disease: the
Atherosclerosis Risk in Communities study
[published online June 12, 2017]. JAMA Intern Med.
doi:10.1001/jamainternmed.2017.1877
2. Havranek EP, Mujahid MS, Barr DA, et al.
Social determinants of risk and outcomes for
cardiovascular disease: a scientific statement from
the American Heart Association. 2015;132(9):
873-898.
3. Fiscella K, Tancredi D, Franks P. Adding
socioeconomic status to Framingham scoring to
reduce disparities in coronary risk assessment.
Am Heart J. 2009;157(6):988-994.
4. Institute of Medicine. Capturing Social and
Behavioral Domains and Measures in Electronic
Health Records: Phase 2. Washington, DC: National
Academies Press; 2014.
5. Adler NE, Glymour MM, Fielding J. Addressing
social determinants of health and health
inequalities. JAMA. 2016;316(16):1641-1642.
6. Campbell F, Conti G, Heckman JJ, et al. Early
childhood investments substantially boost adult
health. Science. 2014;343(6178):1478-1485.

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