Association of Gender and Race With Allocation of Advanced Heart Failure Therapies

Abstract

IMPORTANCE Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. OBJECTIVE To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. EXPOSURE Randomization to clinical vignettes. MAIN OUTCOMES AND MEASURES Thematic differences in allocation of advanced therapies by patient race and gender. RESULTS Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. (continued) Key Points Question Is bias against a patient's gender and race associated with the allocation of advanced heart failure therapies? Findings In a qualitative study of 46 health care professionals, there was more bias against women compared with men when evaluating appearance and social support, particularly among African American women. Fina...

Addressing the Bias in Cardiovascular Care: Missed & Delayed Diagnosis of Cardiovascular Disease in Women

“…Once women have CVD, there are continued sex disparities in their diagnosis, treatment, and management, resulting in worse outcomes for women. Such sex differences have been demonstrated across CVD diagnoses including acute coronary syndromes, heart failure, and valvular disease with delays in care, [13] underutilization of guideline directed medical therapies and cardiac rehabilitation, [2] and less aggressive treatment, [14] , [15] , [16] when compared with men. As a result, we continue to see higher mortality rates and rehospitalizations in women, compared with men.…”

Ventricular Assist Device Technology and Black-White Disparities on the Heart Transplant Wait List

“…23 Two studies by Breathett and colleagues used clinical vignettes to test for physician bias in allocation of advanced heart failure therapies, concluding that racial bias may delay initiation of such therapies in the clinical setting, and may bias decision-making towards recommending destination LVAD therapy, rather than transplant wait listing, for Black patients. 24,25 Although differences in timing of LVAD implantation are concerning for the potential negative impact on outcomes of Black as compared to White heart transplant candidates, we acknowledge that prior evidence demonstrating poorer outcomes with delayed LVAD implantation is limited. For example, Kitada et al described no differences in wait list mortality in an unadjusted analysis of pre- vs. post-listing LVAD implantation, while Brown et al described no impact of absolute duration of LVAD therapy on post-transplant outcomes among patients whose LVAD was implanted for >30 days.…”

Association of race and gender with primary caregiver relationships and eligibility for advanced heart failure therapies

“…performed a national survey of HF clinicians, where clinicians were presented with a clinical vignette describing a patient with advanced HF in need of advanced therapies. All aspects of the clinical presentation including details on medical comorbidities, hemodynamics, adherence with medical therapy, social support, and socioeconomic status were identical, except for the race or gender of the patient being evaluated 20,21 . Discussions with clinicians revealed that women, particularly Black women, were perceived to have more barriers to eligibility for advanced HF therapies, including the assumed burden of childcare and lack of social support.…”

“…and lifestyle. Total scores can be categorized as excellent candidate (0-6), good candidate (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), minimally acceptable candidate (21-39), and high-risk candidate (≥40). Patients who were not evaluated using the SIPAT scoring system (N = 282) were rigorously evaluated by our experienced mental health and social work team for their psychiatric history and stability, as well as their substance use history according to standard criteria.…”