TY - JOUR
T1 - Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care
T2 - A Report From the REVIVAL Study
AU - Cascino, Thomas M.
AU - Colvin, Monica M.
AU - Lanfear, David E.
AU - Richards, Blair
AU - Khalatbari, Shokoufeh
AU - Mann, Douglas L.
AU - Taddei-Peters, Wendy C.
AU - Jeffries, Neal
AU - Watkins, Daphne C.
AU - Stewart, Garrick C.
AU - Aaronson, Keith D.
N1 - Funding Information:
This work was supported by funding from the National Institutes of Health/National Heart, Lung, and Blood Institute (NHLBI contract HHSN268201100026C; K12 HL138039-02 to Dr Cascino), the National Center for Advancing Translational Sciences (NCATS grant UL1TR002240) for the Michigan Institute for Clinical and Health Research, and an Amplifier Grant Award from the Samuel and Jean Frankel Cardiovascular Center.
Publisher Copyright:
© 2022 American Heart Association, Inc.
PY - 2023/1/1
Y1 - 2023/1/1
N2 - Background: Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect. Methods: We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies. Results: The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities. Conclusions: Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making.
AB - Background: Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect. Methods: We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies. Results: The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities. Conclusions: Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making.
KW - decision-making
KW - healthcare disparities
KW - heart failure
KW - social determinants of health
KW - ventricular assist device
UR - http://www.scopus.com/inward/record.url?scp=85146190624&partnerID=8YFLogxK
U2 - 10.1161/CIRCHEARTFAILURE.122.009745
DO - 10.1161/CIRCHEARTFAILURE.122.009745
M3 - Article
C2 - 36259388
AN - SCOPUS:85146190624
SN - 1941-3289
VL - 16
SP - E009745
JO - Circulation: Heart Failure
JF - Circulation: Heart Failure
IS - 1
ER -