Group decision dynamics may impact who receives advanced HF therapies
Key takeaways:
- Advanced HF therapy teams with better scores for group dynamics were more likely to allocate such therapies to women.
- There was no significant effect observed with race and ethnicity and group dynamics.
Better group dynamics among a team of HF specialists are significantly associated with greater likelihood of allocating advanced HF therapies to women, irrespective of patient race and ethnic group, researchers reported.
The regulatory framework for advanced HF therapies in the U.S. delegates eligibility decisions to multidisciplinary groups at the center level; however, the subjective nature of decision-making is at risk for racial, ethnic and gender bias, Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, associate professor of medicine in the division of cardiology, advanced HF/transplant specialist and leader of health equity research at Indiana University School of Medicine and Indiana University Health, and colleagues wrote in the Journal of the American Heart Association.
“We wanted to understand how decisions are made for who receives lifesaving therapies like a heart transplant or a left ventricular assist device for people from minoritized racial/ethnic groups and for women, because we know that these populations are consistently less likely to receive these therapies, but it is not quite clear why,” Breathett, also a Cardiology Today Editorial Board Member, told Healio. “We identified a validated metric to assess group dynamics and assess things such as, are people using research? Are they willing to share opinions in a critical way and admit mistakes? It is that combination of things, when done systematically, that the group dynamics are the strongest.”
Assessing the decision-making process
In a prospective, mixed-methods study, Breathett and colleagues analyzed data from four advanced HF therapy centers, selected for variation in geographic location (different United Network for Organ Sharing regions), the racial and ethnic demographics of city population and heart transplant volume. Advanced HF therapy meetings were audio recorded for at least 1 month.
“Four major centers were willing to participate in this preliminary work, where an audio recording was done at each of their meetings for approximately 1 month or longer until we had an adequate sample of patients observed,” Breathett said. “We did this to see if the group decision-making process is actually associated with the ultimate decision.”
Researchers reviewed transcriptions of the recorded audio from the centers, masked to site and patient demographics, and rated each meeting with scores using the de Groot Critically Reflective Diagnoses protocol. The tool measures categories associated with group dynamics including challenging groupthink, critical opinion sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation. Each category is scaled from 1 (high quality) to 4 (low quality).
The primary outcome was the relationship between group dynamics and the probability of allocation to advanced HF therapies within patient sex, patient race and ethnic groups.
Among 87 patients (24% women; 66% white) evaluated for advanced HF therapies, 57% of women, 38% of men, 44% of white patients and 40% of patients of color were allocated to such therapies, according to the researchers.
“Among patients denied for advanced HF therapies, the majority of all patient groups had medical comorbidities listed as reasons for denial,” the researchers wrote. “Psychosocial reasons were common among over half of women of color, men of color and white men, but only [for] 17% of white women.”
Interaction between group dynamics, allocation by sex
The interaction between group function score and allocation by patient gender was statistically significant (P = .035). Additionally, as group function scores improved, the probability of advanced HF therapy allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups, Breathett said.
The interaction between the scoring metrics and allocation of advanced HF therapies to patients by race and ethnic group was not significant (P = .303). Race and ethnic disparities within gender groups tended to decrease as group function improved, but no statistically significant effect was observed with race and ethnicity, according to researchers. However, when patients were stratified by race group and sex, the pattern of allocation by sex remained.
“Across these four centers combined, women were allocated to advanced HF therapies more often than men, which is big news,” Breathett told Healio. “That is not often the case. Including race and ethnicity, you see a statistically significant interaction. When the group dynamic score is lower — meaning, better — the probability of allocating advanced HF therapies to women is higher. This shows that something special is happening across these sites. This is an area for intervention that may improve allocation to women.”
A national study including 14 sites is currently ongoing to assess the same issues at a larger scale, Breathett said.
“Just like with hypertension control, awareness of this issue is the No. 1 priority,” Breathett said. “Be aware that these issues exist at every institution, not just at ‘other’ institutions. It takes extra work to go against your own biases and move toward equity and antiracism. What are the evidence-based tools and strategies that you can use to change the way care is provided?”
For more information:
Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, can be reached at kbreath@iu.edu.
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