Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries

Abstract

IMPORTANCEWhile left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood. OBJECTIVES To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatment decisions among patients for whom clinician discretion has a more prominent role. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of 12 310 Medicare beneficiaries used 100% Medicare Fee-for-Service administrative claims. Included patients had been

Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study

“…Neither patient preference for receiving a VAD nor a patient’s want to pursue “all life-sustaining therapies” impacted the reduced utilization. In trying to understand how and among whom inequities occur, prior work has demonstrated provider biases in the utilization of advanced therapies for Black candidates, 15,16 and decreased utilization for VAD among “less ideal” candidates either because patients are too sick (eg, more comorbidities) or potentially less ill. 13 Racial differences in treatment preferences have also been proposed as an explanation for disparities in healthcare 8 ; however, the current study demonstrates that in a real-world sample of patients with access to highly specialized care, there is differential utilization of VAD therapy despite similar patient preferences. Taken together, our results suggest that there are factors extrinsic to measurable determinants of VAD candidacy studied (eg, presence of payor, caregiver, and treatment preference) that are impacting utilization and that are likely occurring at the decision-making level.…”

“…Given that race is a sociopolitical framework and not a biological one, 22 race was selected to further understand sociocultural environmental and health care system influences on described disparities in access to advanced therapies. 13,23 The SDoH are “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” 24 The SDoH are generally grouped into domains, including health care access and quality, social and community context, education, economic stability, and neighborhood and built environment. 24 The REVIVAL registry included detailed patient history that could be mapped to the Healthy People 2030 SDoH.…”

“…6,7 Inequities in the use of VAD and transplant among underserved patients are well documented. [8][9][10][11][12][13] The reasons for inequities in access to advanced therapies for underserved groups remain uncertain. Potential explanations have included systemic differences in access to care, patient preference, and provider decision-making, with work primarily focused on differences in access to care and provider decision-making, often with mixed findings.…”

A Fork in the Road to Health Equity—Lesson From Odetta

“…Post hoc analyses were performed to understand how LVAD propensity was associated with outcomes. 2 LVAD propensity of less than 0.52 was associated with lower receipt of LVAD for Black patients vs White patients and higher survival for Black patients vs White patients. In contrast, across all LVAD propensities, women were less likely to receive LVAD than men, and survival was similar by gender.…”

“…Ms Holmes’ work provides insight to the everyday lives of many Black individuals and demonstrates where our focus should be if we desire equity, which is addressing systemic inequality. In JAMA Network Open , Cascino et al sought to address a question of equity in the delivery of life-saving advanced heart failure therapies, left ventricular assist devices (LVAD).…”