Black people and women with severe heart failure who might be good candidates for surgery to implant a heart-assist device are less likely to actually get the surgery than white patients or men, according to a new study.
The differences among black patients arose primarily in patients whose chances of benefiting from a left ventricular assist device (LVAD) were less clear, usually because they had less severe heart failure. This meant that it was up to their healthcare team and the patient to decide whether they wanted to have surgery or continue with non-surgical treatment.
Meanwhile, patterns of LVAD use in women suggest less access no matter how severe their heart failure.
The differences by race and gender persisted even after the researchers took into account a range of factors, from patients’ income and distance from the hospital to what the population mix was like in their neighborhood.
This raises the strong possibility that for these patients, the chance of getting an LVAD was influenced by conscious or unconscious race and gender bias on the part of health care providers, the researchers conclude.
And that means hospitals and heart failure teams must take steps to ensure more equal access to LVAD care for all patients who might benefit, the authors say.
The study, published in JAMA Network Open by a team at the University of Michigan Frankel Cardiovascular Center and the Institute for Health Policy and Innovation, is based on data from more than 12,300 patients with traditional Medicare coverage. All had heart failure severe enough to send them to the hospital at least once in the eight-year study period.
The study shows no racial differences in LVAD use among the sickest heart failure patients, who are the clearest candidates.
In contrast, differences in LVAD use for black patients were clustered among those with less clear need for the device. This need, based on specific clinical characteristics, is measured by what is called the LVAD propensity score. In the group whose scores were “on the bubble,” black patients were significantly less likely to get an LVAD than white or male patients.
The researchers also looked at what happened after patients received an LVAD. In general, patients survived at least one year at equal rates, regardless of their race or sex. Black patients in the “bubble” group were actually more likely to survive at least a year than white patients (84% vs. 77%), although they were slightly more likely to need another hospital stay.
These data show clear racial disparities in cases where there is “leeway” for doctors to decide which patients are most likely to benefit from an LVAD. There is less aggressive use of this life-saving therapy among a subgroup of black patients and all women with heart failure. Although we also need to study the role of patient preference in LVAD decision making for this patient group, heart failure providers should be aware of its potential for bias and how it might influence the recommendations we make to patients”.
Thomas Cascino, MD, MS, lead author, cardiologist and health equity researcher at Michigan Medicine, UM Academic Medical Center
Cascino and colleagues recently studied another aspect of heart failure device care: the use of short-term mechanical circulatory support in heart transplant candidates. This analysis also suggested that variation in center-level utilization plays an important role in this type of care, which in turn could create inequality in a patient’s likelihood of being chosen for a heart transplant when an organ is available. The team published the paper in the Journal of Heart and Lung Transplantation.
Source:
Michigan Medicine – University of Michigan
Journal reference:
Cascino, TM, et al. (2022) Racial and Sex Disparities in Use and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries. Open JAMA Network. doi.org/10.1001/jamanetworkopen.2022.23080.