Pilot test of a multicomponent implementation strategy for equity in advanced heart failure allocation

Breathett, Khadijah; Yee, R D; Pool, Natalie; Hebdon, Megan; Knapp, Shannon M.; Calhoun, Elizabeth A.; Sweitzer, Nancy K.; Carnes, Molly

doi:10.1016/j.ajt.2023.03.005

Cited by 7 publications

(7 citation statements)

References 35 publications

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“…(1) examination of center-level causes and (2) implementation of strategies resulting in equitable offer acceptance (ie, annual incentives for quality, 32 evidence-based bias reduction and antiracism training 33 ).…”

Section: Discussionmentioning

confidence: 99%

“…These issues could be generated from a false security that Black patients and/or men can wait longer for a better offer or from greater fear of a bad outcome with selecting an “imperfect” donor for a particular race and/or gender. Unconscious bias and structural racism may be studied and perhaps remedied by providing transplant center–level acceptance and waiting list survival data by race, ethnicity, and gender to centers and incentivizing (1) examination of center-level causes and (2) implementation of strategies resulting in equitable offer acceptance (ie, annual incentives for quality, evidence-based bias reduction and antiracism training).…”

Section: Discussionmentioning

confidence: 99%

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Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Breathett,

Knapp,

Lewsey

et al. 2024

JAMA

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ImportanceBarriers to heart transplant must be overcome prior to listing. It is unclear why Black men and women remain less likely to receive a heart transplant after listing than White men and women.ObjectiveTo evaluate whether race or gender of a heart transplant candidate (ie, patient on the transplant waiting list) is associated with the probability of a donor heart being accepted by the transplant center team with each offer.Design, Setting, and ParticipantsThis cohort study used the United Network for Organ Sharing datasets to identify organ acceptance with each offer for US non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) adults listed for heart transplant from October 18, 2018, through March 31, 2023.ExposuresBlack or White race and gender (men, women) of a heart transplant candidate.Main Outcomes and MeasuresThe main outcome was heart offer acceptance by the transplant center team. The number of offers to acceptance was assessed using discrete time-to-event analyses, nonparametrically (stratified by race and gender) and parametrically. The hazard probability of offer acceptance for each offer was modeled using generalized linear mixed models adjusted for candidate-, donor-, and offer-level variables.ResultsAmong 159 177 heart offers with 13 760 donors, there were 14 890 candidates listed for heart transplant; 30.9% were Black, 69.1% were White, 73.6% were men, and 26.4% were women. The cumulative incidence of offer acceptance was highest for White women followed by Black women, White men, and Black men (P &lt; .001). Odds of acceptance were less for Black candidates than for White candidates for the first offer (odds ratio [OR], 0.76; 95% CI, 0.69-0.84) through the 16th offer. Odds of acceptance were higher for women than for men for the first offer (OR, 1.53; 95% CI, 1.39-1.68) through the sixth offer and were lower for the 10th through 31st offers.Conclusions and RelevanceThe cumulative incidence of heart offer acceptance by a transplant center team was consistently lower for Black candidates than for White candidates of the same gender and higher for women than for men. These disparities persisted after adjusting for candidate-, donor-, and offer-level variables, possibly suggesting racial and gender bias in the decision-making process. Further investigation of site-level decision-making may reveal strategies for equitable donor heart acceptance.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Breathett,

Knapp,

Lewsey

et al. 2024

JAMA

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“…7,26,72 The SOCIAL HF pilot study used the COM-B/BCW framework to systematically improve the decision-making process in allocating advanced HF therapies by using evidencebased strategies that affect an individual's capability, opportunity, and motivation for change. 28 The intervention included longitudinal trainings on implementation of antiracism and bias reduction strategies, use of more objective assessments of social support and adherence, and strategies to improve group dynamics. The study used a mixed-methods design with preintervention and postintervention testing incorporating normalization process theory (framework for developing, implementing, and evaluating a complex system-level intervention 73 ) for evaluation.…”

Section: Implementation Science Studies For Hf Treatment Focused On E...mentioning

confidence: 99%

“…16 By understanding these factors, implementation scientists can develop and test strategies to promote widespread, equitable adoption of guideline-directed medical therapy (GDMT) for HF management. 28…”

Section: Defining Implementation Science and Relationship With Equitymentioning

confidence: 99%

Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association

Breathett,

Lewsey,

Brownell

et al. 2024

Circulation

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Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.

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“…Employ a conceptual model routed in cardiovascular disparities developed by and with experts in cardiovascular disparities. 17 Dare to focus studies on leading contributors of cardiovascular disparities, bias, social determinants of health, and structural racism. Engage in rigorous implementation science, community-based participatory research, and mixed-method studies centered on achieving cardiovascular equity.…”

mentioning

confidence: 99%

Catalyzing Restructure of a Broken Health Care System

Breathett,

Manning

2024

Circ: Cardiovascular Quality and Outcomes

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Pilot test of a multicomponent implementation strategy for equity in advanced heart failure allocation

Cited by 7 publications

References 35 publications

Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association

Catalyzing Restructure of a Broken Health Care System

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