‘Access to care is key’: Closing the race disparity gap in heart transplant
Key takeaways:
- Black patients are less likely to receive a heart transplant compared with other races.
- Social determinants of health, including income and ZIP code, play a role in heart transplant access and outcomes.
Editor's Note: This is part 2 of a three-part Healio Exclusive series on developments and challenges in heart transplantation. Part 1 can be viewed here. Part 3 can be viewed here.
Heart transplant is the most effective treatment for end-stage HF but it is also the scarcest of HF therapies — particularly for patients from underrepresented racial and ethnic groups.
Despite efforts from professional societies to reduce inequities in transplant access, the gap between heart transplant rates and HF mortality is largest for Black patients compared with other races, according to a 2021 analysis published in Circulation. Inequities in transplantation can be attributed to limited data on patients’ social determinants of health and provider bias.
“Black patients with left ventricular assist devices awaiting heart transplant are less likely to achieve transplantation, more likely to be delisted, and more likely to die after transplant,” Healio | Cardiology Today Editorial Board Member 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, wrote in the analysis. “Five‐year posttransplant survival is lowest in Black recipients; however, more equitable survival outcomes are possible with multidisciplinary team care.”
Transplant data by ZIP code
In a study presented at the 2023 International Society for Heart and Lung Transplantation Annual Meeting and Scientific Sessions, researchers identified 32,494 adult recipients of first-time, isolated heart transplants from 2005 to 2020. The researchers characterized ZIP code-level socioeconomic disadvantage using the Distressed Communities Index, based on education level, poverty, unemployment, housing vacancies, median income and business growth, and compared heart transplant recipients from distressed communities (n = 5,043) with all others (n = 27,451).
The researchers found that recipients from the most distressed communities were more likely to come from historically underrepresented backgrounds, were less educated and were more likely to have public insurance. They received transplants at lower-volume centers and lived farther away from their transplant center. After transplant, the recipients from distressed communities had more acute rejection episodes before initial discharge (12.7% vs. 10.4%), more readmissions within 1 year (40.5% vs. 38.5%) and worse 5-year survival (75% vs. 79.2%; P for all < .01).
Disparities ‘relate to access to care’
“Transportation, psychosocial and social issues, employment and education, languages spoken — these are all disparities and all relate to access to care,” Healio | Cardiology Today Editorial Board Member Jon Kobashigawa, MD, director of the advanced heart disease division and of the heart transplant program at the Smidt Heart Institute at Cedars-Sinai, as well as associate director of the institute, said in an interview. “When accounting for age, race and insurance, these disparities do cause more adverse outcomes. How do we change these outcomes? It is a global issue. It is not just one where we only look at what we can do for someone in poverty. Access to care is key. How do we make sure these patients with advanced heart disease are followed?”
In 2018, the United Network for Organ Sharing (UNOS) revised the organ allocation system from three tiers to six tiers to expand access to organs for the most medically urgent patients and reduce disparities as well as regional differences. However, in an analysis published in August 2021 in the Journal of the American Heart Association, researchers found that Black, Hispanic and white patients all had increased likelihood of transplant, but disparities still persist, with Black patients having lower likelihood of transplant than white patients (adjusted HR = 0.87; 95% CI, 0.84-0.9; P < .001). Black patients also continued to have a higher risk for death after heart transplant (aHR = 1.14; 95% CI, 1.04-1.24; P = .004).
“Cardiac transplant in particular is done more commonly in white people,” Healio | Cardiology Today Editorial Board Member Mary Norine Walsh, MD, MACC, medical director of heart failure and transplantation at St. Vincent Heart Center in Indianapolis and past president of the American College of Cardiology, said during an interview. “What has been clearly demonstrated in transplant is we have evidence of implicit bias, of tending to not list some individuals for transplant. Such underrepresentation of some groups is inequity.”
A larger issue is the patients who are never referred for heart transplant, according to Seth Hollander, MD, pediatric cardiologist and medical director of heart transplantation at Stanford Medicine Children’s Health. Hollander said it is important to make sure there is also equity within transplant selection committees.
“Who goes on the transplant list, and how do those discussions happen?” Hollander told Healio. “Who is on the transplant selection committee? Who is representing the needs of certain cultural groups, be it race groups or language or immigration status groups? People being considered for transplant should have their unique worldviews represented.”
In a study published in March in the Journal of the American Heart Association, researchers found that 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.
Understanding provider bias
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, Breathett said in an interview.
“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 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.”
For the study, Breathett and colleagues analyzed data from four advanced HF therapy centers, selected for variation in geographic location (different UNOS 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.
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 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.”
“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?”
Adam D. DeVore, MD, associate professor of medicine at Duke University School of Medicine and member in the Duke Clinical Research Institute, said inequities also persist in HF prevention, diagnosis and early treatment.
“Heart transplant is centralized to a few centers, so there are geographic limitations when people struggle with socioeconomic challenges struggle to travel far to receive care,” DeVore told Healio. “You can envision a world where, if we are getting better at noninvasive monitoring and doing a better job with remote telecare, we could deliver this more equitably. I hope we can use these tools to address some of these challenges.”
Editor’s Note: Part 3 of this Healio Exclusive series will discuss the inefficiencies of the listing system for heart transplantation and other improvements that could be made in the future.
We want to hear from you:
Healio wants to hear from you: What strategies do you think could help close the gaps in heart transplant care? Share your thoughts with Healio by emailing the author at rschaffer@healio.com or tweeting @CardiologyToday. We will contact you if we wish to publish any part of your story.
References:
- Breathett K, et al. J Am Heart Assoc. 2023;doi:10.1161/JAHA.122.027701.
- Breathett K, et al. Circulation. 2021;doi:10.1161/CIRCULATIONAHA.120.052254.
- Chen Q, et al. Heart transplantation outcomes in patients from socioeconomically distressed communities. Presented at: International Society for Heart and Lung Transplantation Annual Meeting & Scientific Sessions; April 19-22, 2023; Denver.
- Chouairi F, et al. J Am Heart Assoc. 2021;doi:10.1161/JAHA.120.021067.
- Madan S, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.04.022.
For more information:
Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, can be reached at kbreath@iu.edu.
Adam DeVore, MD, can be reached at adam.devore@duke.edu; Twitter: @_adevore.
Seth Hollander, MD, can be reached at sethh1@stanford.edu; Twitter: @sethhollander.
Jon Kobashigawa, MD, can be reached at jon.kobashigawa@cshs.org.
Mary Norine Walsh, MD, MACC, can be reached at macwalsh@iquest.net; Twitter: @minnowwalsh.
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