Black patients less likely to receive VADs, heart transplants than white patients
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Among adults with advanced HF, Black patients were less likely than white patients to receive a ventricular assist device or a heart transplant, according to the results of the REVIVAL prospective cohort study.
“Prior work has shown convincingly that there are racial disparities in access to lifesaving therapies for patients with severe heart failure. There are several potential explanations for these disparities including access to care and patient preferences for care,” Thomas M. Cascino, MD, a clinical instructor in the division of cardiovascular disease at the University of Michigan at Ann Arbor, told Healio. “We build on this work by looking at the use of left ventricular assist devices (LVAD) and transplant among patients who have high-risk heart failure who are receiving care at expert centers. Additionally, we asked patients about their care preferences for LVADs.”
Disparities in patients at VAD centers
Cascino and colleagues conducted the prospective, observational REVIVAL study to determine whether race was associated with VAD use and heart transplants in patients with access to care at VAD centers.
The cohort included 377 patients (26.5% Black; 25% women; mean age, 60 years) from 21 VAD centers who had high-risk features and no contraindications for VAD. Patients were followed for 2 years. The primary outcomes were VAD or transplant and death.
During the study period, 11% of Black patients (VAD, 8%; transplant, 3%) and 22.3% of white patients (VAD, 15.5%; transplant, 6.9%) received a VAD or heart transplant and 18% of Black patients and 13% of white patients died, Cascino and colleagues wrote in Circulation: Heart Failure.
After adjustment, Black race was associated with reduced utilization of VAD and transplant (adjusted HR = 0.45; 95% CI, 0.23-0.85). However, there was no difference by race in risk for death (HR = 1.23; 95% CI, 0.67-2.25).
“We found that Black people with high-risk heart failure were less likely to receive ventricular assist devices and transplants than white people,” Cascino told Healio. “This was true despite receiving their care from LVAD/transplant cardiologists and taking into consideration heart failure severity and patient-reported health-related quality of life, the two main reasons to pursue these therapies. Patient preferences for receiving an LVAD were not the reason for the inequities.”
Worse Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) patient profile predicted death at 2 years (HR = 1.95; 95% CI, 1.58-2.39), whereas higher BMI (HR = 0.938; 95% CI, 0.893-0.985) and presence of a caregiver (HR = 0.41; 95% CI, 0.22-0.76) predicted survival at 2 years, according to the researchers.
Results ‘disconcerting’
“These results are disconcerting. This study suggests that racial inequities in access to these lifesaving therapies may occur from differential provider decision making because of structural racism and discrimination or provider biases,” Cascino told Healio. “We as providers must acknowledge our role in perpetuating current inequities if we are to engender change. There is a need to review our current care processes from the onset of heart failure to heart failure specialist referral to patient selection for advanced therapies.”
He said there are a number of actions that can be taken promptly to try to reduce these disparities.
“Centers should monitor the patterns of care and outcomes for their heart failure population by race to better understand local disparities and inequities in access. All providers should receive implicit bias training. There is an opportunity to involve health equity experts to review our decision-making processes with standardization whenever possible,” Cascino told Healio. “Long-term, there is a need to engage underserved communities and stakeholders asking how we can do better and ultimately developing a meaningful partnership.”
For more information:
Thomas M. Cascino, MD, can be reached at tcascino@med.umich.edu.
Perspective
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Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA
This study highlights the need for implementation science research in advanced HF. Like many others, this study has illustrated that race is associated with the allocation of advanced HF therapies. Black patients are less likely to be offered a heart transplant than white patients with similar risks. My prior work evaluating step by step how health care professionals make decisions about allocation has revealed that the most significant disparities are related to bias, subjectivity in the social history assessment and group dynamics of the allocation team. I am leading SOCIAL HF, a national randomized controlled pragmatic cluster trial/implementation science type 2 study (www.clinicaltrials.gov/ct2/show/NCT05390411) that intervenes on each of these etiologies and examines how readily sites are able to make changes. We hypothesize that intervening on these etiologies will lead to higher allocation rates for patients of color and women.
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