Patient sex, race may impact decision-making for heart transplant, VAD allocation
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In a survey of cardiac clinicians, researchers found that neither sex nor race of a patient predicted allocation of HF therapies, although bias was observed in the form of harsher judgment of women overall, particularly for Black women.
“As illustrated in this study, the current allocation process for advanced HF therapies (heart transplants and ventricular assist devices [VAD]) is subjective and at risk for bias,” Khadijah Breathett, MD, MS, assistant professor of medicine in the division of cardiology at the University of Arizona in Tucson, advanced heart failure and transplant cardiologist at Banner – University Medical Center in Tucson, told Healio. “In this study of health care professionals who make decisions regarding advanced therapies across the U.S., patient race and gender influenced the decision-making process. Although health care professionals were randomized to patients with identical clinical and social histories, social support assessments were biased against women, particularly African American women; however, the final recommendations did not differ by race and gender.”
For this study, published in JAMA Network Open, researchers interviewed 46 U.S. clinicians (52% women; 43% from underrepresented groups) at an international heart transplantation conference in April 2019. Clinicians were shown clinical vignettes of Black and white men and women, all with similar HF profiles and histories, and discussed the decision-making process using the think-aloud technique. Clinicians were then surveyed on their final judgments for allocation of HF therapies.
Researchers noted five prevalent themes during the think-aloud interviewing process.
Five themes
First, the clinical vignettes of women were critiqued harshly for appearance, age, hair and facial expression.
“When I see her, I don’t think of her as totally friendly, I see someone who’s a little unkempt to some extent, and yet she’s probably fine and normal. That was my immediate reaction of not wanting the photo. Because I’m now making a decision about whether she is capable of taking care of herself or a machine based on her hair. Maybe there’s value there, but that’s not how we do it. And so, I was upset to see the photos. So anyway, that’s my feeling,” a white woman participant said about the white woman vignette.
Second, the Black man was perceived as being severely ill compared with participants in the other vignettes, according to the study.
“His risk of death in the next few months is very high. Again, still can’t decide his eligibility, but it means it may be indicated in an urgent setting for transplantation down the road,” a white man participant said about the Black man vignette.
Third, participants expressed high concern for the prior care of the Black woman compared with the white woman, researchers reported.
"It’s a shame that this lady was only diagnosed 2 years ago. I mean I get angry about that. I mean particularly being a [minority] provider, I see that many patients that are referred to me regardless of their race tend to be referred late from a heart failure standpoint. I find that my minority patients, particularly my African American patients, are referred even later. ... Many times it’s because their symptoms were going unrecognized by the people that were taking care of them ... or their symptoms weren’t believed. ... They tell me many stories and I’m hoping that this isn’t the case for her but unfortunately if you see it enough times ... it starts to dishearten you” a minority man participant said about the Black woman vignette.
Fourth, the clinicians expressed concern for social support for women and perceived children as liabilities for Black women, especially.
“I’m just worried about the fact that she’s taking care of little kids. She does have a spouse who will be her caregiver and so she does have support but I mean thus far nothing is a red flag, it’s just concern that those 2 kids need to be taken care of but she’s in the hospital,” a minority man participant said about the Black woman vignette.
Fifth, in the interview and the supplemental survey, the final recommendations for treatment were similar for both the Black woman and white woman vignettes:
“It’s just really challenging. I mean, you meet a person and they’re underinsured. They have a family, they’re a regular person, right? It’s easier when someone doesn’t have anyone; they’re divorced or they’ve never had kids and … they failed completely on the social side, but she’s got enough soft things that will make it challenging, and in our program, we would say, ‘We’ll take a chance on her for a VAD but not for a heart,” a white man participant said of a patient vignette of a white woman.
- heart transplantation (mean Likert score rating, 7.53 vs. 6.53; P = .56);
- bridge-to-transplant VAD (8.11 vs. 7.78; P = .79);
- destination therapy (7 vs. 7.48; P > .99); and
- no therapies (1.4 vs. 1.43; P >. 99).
Recommendations for therapies
Recommendations for VAD were more prevalent for the Black man vignette compared with the other vignettes (eg, bridge-to-transplant VAD, 8.21 for the Black man vs. 7.7 for the white man).
Additionally, clinician support for advanced therapies was greater for the Black woman vignette compared with the others (eg, no therapy, 1.4 for Black woman vs. 1.96 for white man).
“In the U.S., women receive less than a quarter of advanced therapies and racial/ethnic minorities receive less than one-third,” Breathett said in an interview. “Given the need for appropriate social support prior to allocating advanced therapies, this study elucidates mechanisms for race and gender inequities in advanced HF therapy (ie, delays in care and denial of advanced therapies). In order to achieve health equity, advanced therapy centers should consider initiating steps to reduce bias and increase objectivity in the allocation process. The next phase of my clinical research aims to address these barriers to equity.”
Understanding biases, decreasing disparities
“Social determinants of health play a key role in the assessment of candidates before placement on a waiting listing for a transplantation and should be taken into account to develop an active framework to minimize health disparities in cardiovascular health,” Bessie A. Young, MD, MPH, professor in the division of nephrology, section head of the VA Puget Sound Health Care System and associate chair for diversity and inclusion at the University of Washington, wrote in a related editorial. “Expanding access to care has increased the availability of heart transplantation for African American patients with Medicaid insurance, findings that were not uniform for patients from other minority groups. Understanding biases that may contribute to the allocation process are important and will allow for the standardization of that process, improvement in access to advanced heart failure therapies for women and patients from minority groups, and development of interventions aimed at decreasing health disparities in the assessment process.”
Reference:
Editor’s Note: This article was updated on July 24, 2020 with new descriptions of the clinical vignettes as requested by Dr. Breathett.
Perspective
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Alanna Morris, MD, MSc, FHFSA, FACC, FAHA
The study approach is innovative and addresses a critically important question within advanced HF — is practitioner bias among the reasons why women are less likely to get advanced HF therapies? When you look at the data, the number of patients who get listed for heart transplantation has been growing rapidly over the past decade, however the proportion of women candidates during that time period has been stagnant around 25%. That number seems low compared with the number of women with prevalent HF, and compared with epidemiologic data that suggest women are more likely to die of HF than men. So we really need more innovative studies like this one to understand the different factors that are driving those disparities.
Awareness of implicit bias is key. Most studies show that if you explicitly ask health care providers if they have bias against race or sex, they will say almost universally say no. However, objective research methods to detect implicit bias, using the implicit association tests or other study designs such as this one that utilize clinical vignettes, will show evidence of implicit bias among health care providers. It is important to note that the investigators almost present two studies in one. In the surveys that utilized a Likert scale, treatment allocation to heart transplant or LVAD did not differ between Black and white women; when the results for women were compared to men, white women were least likely to be recommended for LVAD, though it is unclear if this difference is statistically significant. However, the think-aloud interviews revealed that there are themes that suggest women are judged more harshly related to social support, particularly the perception of children as liabilities that would make it more difficult for women to access advanced HF therapies. Since most multidisciplinary meetings to decide candidacy occur behind closed doors and the discussions are considered to be confidential, we need to find ways to integrate checkpoints within those meetings to protect patients against the potential for bias affecting decision making.
Critics of this study would argue that it is a small sample size, with hypothetical situations (including the use of pictures, which most programs don’t use in selection committees to make judgments about patient candidacy). However, we currently don’t have national data that examines how decisions are made — ie, who is reviewed as a candidate for advanced therapies, and who actually gets advanced therapies. We need more studies that examine the pipeline from initial diagnosis of advanced HF all the way to who gets the therapies in the end.
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