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.

Solutions
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 care^25,26) 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.

References

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22. 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.
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25. 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.
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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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