Health Disparities in Advanced Heart Failure Treatment

Abstract

Heart failure is a costly, morbid condition that is estimated to affect approximately 6.2 million individuals in the United States at a cost of $30.7 billion, which is estimated to increase to $69.8 billion by 2030. Overall, the incidence typically starts several decades earlier 2 and is associated with greater morbidity and mortality in African American than white individuals. rican American men have the highest age-adjusted death rate for heart failure (118.2 per 100 000), followed by non-Hispanic white men (111.3 per 100 000), African American women (86.0 per 100 000), and white women (80.4 per 100 000). 1 After medical management is no longer effective, advanced therapies for heart failure, such as ventricular assist devices (VAD), improve quality of life and survival and can be used as terminal treatment or as a bridge to heart transplantation. 1,3 However, after receiving a transplantation, African American patients have a 1.4-fold greater risk of graft failure and 1.3-fold greater risk of death compared with white patients. 1 They are more likely than white patients to be treated at centers with higher than expected mortality rates, even after adjusting for insurance and education level. 1 Analyzing data from the United Network of Organ Sharing (UNOS), Lui et al 4 found that among patients bridged to heart transplantation using VAD, African American individuals were more likely to have increased odds of graft failure and death compared with white patients. Conversely, a multicenter trial that used a specific VAD to bridge to transplantation 5 found no differences in survival by race or sex. Differences in graft rejection and survival have been attributed to socioeconomic status, insurance status, and race/ethnicity, although controversy exists. Analogous to the groundbreaking and disturbing 1999 study by Schulman and colleagues 9 that assessed physician recommendations for cardiac catheterization referral and showed that both women and African American patients with the same clinical history were much less likely than men and white patients, respectively, to be referred for cardiac catheterization, Breathett and colleagues 8 evaluated whether patient gender and race were associated with clinician decision-making regarding the allocation of heart transplantation using clinical vignettes (ie, clinical histories) of patients with terminal heart failure. Similar to a 2019 study 7 that evaluated racial disparities in access to advanced cardiac therapies for heart failure in men, in this study, Breathett et al 8 evaluated whether bias was involved in recommendations for or against advanced heart therapies for women compared with men and for African American patients compared with white patients. Participants included US health care professionals attending an international cardiac transplantation meeting, who were asked to describe their decision-making processes. Participants were randomized to receive vignettes with a photo of an African American woman or man or a white woman or man. The study found that many of the participants did not want to look at the photos; however, when they did, some had negative impressions of the patients, which may have subsequently affected their judgments for recommendations of advanced therapies.

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