Latest Evidence on Racial Inequities and Biases in Advanced Heart Failure
- Heart failure disparities are worsening across race, ethnicity, and sex.
- Social determinants of health including bias and racism impact cardiovascular care.
- Research to achieve equity in heart failure is urgently needed.
Heart Failure Inequities
Heart failure inequities expand across race, ethnicity, and sex.1 African-Americans and Hispanics have a higher prevalence of heart failure than Whites.1 African-American women have a higher prevalence of heart failure than any other intersection of race and sex in the US.1 African-Americans of both sexes are disproportionately dying from heart failure compared to other races and ethnicities, particularly among younger age groups (35-64 years).2 Compared to men and Whites, women and racial or ethnic minorities are less likely to receive appropriate medical therapy,3-5 implantable cardioverter-defibrillators or cardiac resynchronization therapy with defibrillator,4,6,7 and be included in clinical trials.8,9 Race is also associated with the likelihood of receiving care by a cardiologist during an intensive care unit hospitalization for heart failure, and the odds of receiving care was the lowest among African-American men.10 In addition, racial and ethnic minorities receive less than 40% of total annual advanced heart failure therapies, heart transplants and ventricular assist devices (VAD), and women receive less than a quarter of advanced heart failure therapies.11,12
Societal Contributions to Inequity
A landmark report by the Institute of Medicine, Unequal Treatment, raised awareness of racial and ethnic disparities in health.13 This 2003 report acknowledged that racial and ethnic inequities in disease prevalence and clinical care have existed for multiple centuries. Racial and ethnic minorities have been abused through experimentation (Tuskegee, sterilization surgery), intentional inferior care (segregation, Jim Crow era), and treated as dispensable members of society (organ theft).13,14 A pivotal study from 1999 demonstrated how bias impacts cardiovascular care decisions of health care professionals where African-American women were significantly less likely to be offered appropriate care than other groups.15 Social determinants of health were heralded as key etiologies of past and current disparities, including bias and racism.13 Strategies to manage social determinants of health ranged from changes in policy to expand access to equitable care to cultural competency education to improve the quality of patient and health care professionals' interactions.13 Urgency was relayed in the need for research to study interventions for health equity.
Two decades later, rapid advances have occurred in the medical and procedural care of heart failure patients, but little change has occurred in racial, ethnic, and sex disparities. A recent meta-synthesis revealed that patient race and ethnicity continue to influence clinical decision-making of physicians.16 Five major domains influenced physicians' race-based clinical decision-making: different perceptions on the importance of race, patient-level issues (barriers to access, comorbidities), system-level issues (inadequate ancillary support or time), patient values (low trust in the health care system), communication (same language and culturally appropriate communication), and bias or racism.
Healthcare Professional Bias in Advanced Heart Failure
Bias in the management of advanced heart failure has been observed in recent studies. In one national study, over 400 health care professionals who make decisions about advanced heart failure therapies were randomized to an African-American or White man patient vignette with identical clinical and social histories.17 Using a survey, participants rated the impact of sociodemographic and clinical factors in their decision-making and rated the appropriateness of allocation choices (transplant, VAD, no therapy). Participants also provided demographic information. Approximately 10% of participants underwent interviews in order to understand their reasoning for and against offering advanced heart failure therapies. The most important factors contributing to the decision to recommend heart transplant or bridge to transplant VAD were social support and adherence. Overall ratings for different advanced therapies did not vary by patient race; however, African-American patient race and being an older health care professional were associated with reduced likelihood of recommending a heart transplant. Interviews revealed bias against African-American men. Assessments of social support and adherence were judged more poorly among African-Americans than Whites. The African-American man was thought to be less trustworthy than the White man. In the interviews, heart transplant was recommended for the White man but not for the African-American man.
In a smaller related national study, the intersecting roles of patient gender and race were examined in the allocation of advanced heart failure therapies.18 Health care professionals who make decisions about advanced heart failure therapies were randomized to either an African-American woman (n=20), White woman (n=20), African-American man (n=3), or White man patient vignette (n=3) in order to compare with a prior study.17,18 Vignettes had identical clinical and social histories, similar to a prior study. Participants were interviewed and surveyed about their decision-making process and factors that influenced the allocation of advanced heart failure therapies. Surveys revealed no racial or gender difference in the allocation of advanced heart failure therapies, but bias was revealed in the decision-making process. In the interviews, women's appearance was judged more harshly than men. The African-American man was perceived as more sick than other groups. Women were perceived as having inadequate social support compared to men even though social support was identical. Children were considered liabilities for women, particularly African-American women. The African-American woman was perceived as having more financial issues and problems with family dynamics than other groups. In the interviews, VAD was recommended over transplant for all groups. Although a smaller study, this study revealed how bias may contribute to disparities in heart transplant allocation and potentially to delays in care.
The Institute of Medicine report, Unequal Treatment, may be more relevant now than ever before.13 COVID-19 has illustrated how gaps for health care have widened by race and in some cases by sex due to social determinants of health, including bias and racism.19,20 Allocation of heart transplants have dramatically dropped during COVID-19,21 and the implications on existing racial and gender disparities remain to be seen. Health care organizations, policymakers, and health care professionals have the duty to change the status quo.
Structural solutions are needed to replace the structural inequalities culpable for race and gender disparities in heart failure. Multi-faceted interventions may be more likely to achieve equity than individual interventions since social determinants of health are composed of multiple dynamic parts (i.e. insurance, education, housing, wealth, racism).22-24 Evidence-based strategies include policies that expand access to care25,26) and bias reduction training.27,28 Bias reduction or anti-racism training has shown promise in increasing diversity among health care professionals and may directly and indirectly improve clinical care delivery.27,28 Research is urgently needed to understand how to disseminate and implement interventions that achieve equity in advanced heart failure. Heart failure patients deserve better, and the US health care system can achieve cardiovascular equity.
- Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics—2020 Update: a report from the American Heart Association. Circulation 2020;141:e139-e596.
- Glynn P, Lloyd-Jones DM, Feinstein MJ, Carnethon M, Khan SS. Disparities in cardiovascular mortality related to heart failure in the United States. J Am Coll Cardiol 2019;73:2354–5.
- Harjai KJ, Nunez E, Humphrey JS, Turgut T, Shah M, Newman J. Does gender bias exist in the medical management of heart failure? Int J Cardiol 2000;75:65–9.
- Shah RU, Klein L, Lloyd-Jones DM. Heart failure in women: epidemiology, biology and treatment. Womens Health (Lond) 2009;5:517–27.
- Chan PS, Oetgen WJ, Buchanan D, et al. Cardiac performance measure compliance in outpatients: the American College of Cardiology and National Cardiovascular Data Registry's PINNACLE (Practice Innovation and Clinical Excellence) program. J Am Coll Cardiol 2010;56:8–14.
- Farmer SA, Kirkpatrick JN, Heidenreich PA, Curtis JP, Wang Y, Groeneveld PW. Ethnic and racial disparities in cardiac resynchronization therapy. Heart Rhythm 2009;6:325–31.
- Hsich EM. Sex Differences in Advanced Heart Failure Therapies. Circulation 2019;139:1080–93.
- Sullivan LT 2nd, Randolph T, Merrill P, et al. Representation of black patients in randomized clinical trials of heart failure with reduced ejection fraction. Am Heart J 2018;197:43–52.
- Jin X, Chandramouli C, Allocco B, Gong E, Lam CSP, Yan LL. Women's participation in cardiovascular clinical trials from 2010 to 2017. Circulation 2020;141:540–8.
- Breathett K, Liu WG, Allen LA, et al. African Americans are less likely to receive care by a cardiologist during an intensive care unit admission for heart failure. JACC Heart Fail 2018;6:413–20.
- Colvin M, Smith JM, Hadley N, et al. OPTN/SRTR 2017 Annual Data Report: Heart. Am J Transplant 2019;19 Suppl 2:323–403.
- Breathett K, Allen L, Helmkamp L, et al. Temporal trends in contemporary use of ventricular assist devices by race and ethnicity. Circ Heart Fail 2018;11:e005008.
- Smedley B, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (National Academies Press website). 2003. Available at: https://download.nap.edu/openbook.php?isbn=030908265X . Accessed 06/02/2012.
- Jones C. The Organ Thieves: The Shocking Story of the First Heart Transplant in the Segregated South. Gallery/Jeter Publishing; Illustrated Edition; 2020.
- Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:618–26.
- Breathett K, Jones J, Lum HD, et al. Factors related to physician clinical decision-making for African-American and Hispanic patients: a qualitative meta-synthesis. J Racial Ethn Health Disparities 2018;5:1215–29.
- Breathett K, Yee E, Pool N, et al. Does race influence decision making for advanced heart failure therapies? J Am Heart Assoc 2019;8:e013592.
- Breathett K, Yee E, Pool N, et al. Association of gender and race with allocation of advanced heart failure therapies. JAMA Netw Open 2020;3:e2011044.
- Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among Black patients and White patients with Covid-19. N Engl J Med 2020;382:2534–43.
- Health Equity Considerations & Racial & Ethnic Minority Groups (CDC website). 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html . Accessed 09/01/2020.
- DeFilippis EM, Sinnenberg L, Reza N, et al. Trends in US Heart Transplant Waitlist Activity and Volume During the Coronavirus Disease 2019 (COVID-19) Pandemic. JAMA Cardiol 2020;5:1048-52.
- Havranek EP, Mujahid MS, Barr DA, et al. Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2015;132:873–98.
- Sims M, Kershaw KN, Breathett K, et al. Importance of housing and cardiovascular health and well-being: a scientific statement from the American Heart Association. Circ Cardiovas Qual Outcomes 2020;13:e000089.
- Nayak A, Hicks AJ, Morris AA. Understanding the complexity of heart failure risk and treatment in Black patients. Circ Heart Fail 2020;13:e007264.
- Breathett K, Allen LA, Helmkamp L, et al. The Affordable Care Act Medicaid Expansion correlated with increased heart transplant listings in African-Americans but not Hispanics or Caucasians. JACC Heart Fail 2017;5:136–47.
- McMorrow S, Long SK, Kenney GM, Anderson N. Uninsurance disparities have narrowed for Black and Hispanic adults under The Affordable Care Act. Health Aff (Millwood) 2015;34:1774–8.
- Devine PG, Forscher PS, Cox WTL, Kaatz A, Sheridan J, Carnes M. A gender bias habit-breaking intervention led to increased hiring of female faculty in STEMM departments. J Exp Soc Psychol 2017;73:211–5.
- Capers Q 4th, Clinchot D, McDougle L, Greenwald AG. Implicit racial bias in medical school admissions. Acad Med 2017;92:365–9.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support
Keywords: Heart Failure, African Americans, Ethnic Groups, Cultural Competency, Racism, Cardiac Resynchronization Therapy, Heart-Assist Devices, Defibrillators, Implantable, Prevalence, Housing, Family Relations
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