Does Race Influence Decision Making for Advanced Heart Failure Therapies?

Abstract

BackgroundRace influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies.Methods and ResultsMembers of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation.ConclusionsBlack race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

Bias and stereotyping among research and clinical professionals: Perspectives on minority recruitment for oncology clinical trials

“…Participant data were collected in 2010, and it is possible that professional perspectives have changed over the years. However, more recently published data have suggested that bias based on race and ethnicity not only persists but influences decision making in health care settings similar to those in which recruitment for clinical trials takes place . Although the stakeholder data corresponded to only some of the data in the previous literature, we cannot rule out the possibility that stakeholders' views are informed both by their personal experience and previously published literature regarding racial disparities in clinical trial participation.…”

Sex differences in eligibility for advanced heart failure therapies

“…Women are diagnosed and referred for advanced HF therapies later in the course of their disease, which may be due to atypical disease presentations, but may also be due to implicit bias on the part of providers. 7,36 A recent analysis by Breathett et al 37 confirms that implicit bias does influence decision making for advanced HF therapies. Bias may be particularly important for women who are attempting to access advanced HF therapies, since the psychosocial and socioeconomic determinants of health may have a greater impact on women than men.…”

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

“…Conversations rather than surveys guide these allocation meetings, and more dominant members may lead the conversations and control the final decision. 7 In addition, the differences in concerns by gender and race could contribute to a delay in treatment, which could worsen outcomes.…”

“…Association of Gender and Race With Allocation of Advanced Heart Failure Therapies purposefully selected for diversity of participant demographic characteristics (ie, gender, race, geography, and years past training). Snowball sampling was used to meet an enrollment goal of 44 participants because it was sufficient to reach 1:1 thematic saturation in a prior study 7 and snowball sampling is an established method of recruiting specific hard-to-reach subgroups. 14…”