Denial for Advanced Heart Failure Therapies Due to Psychosocial Stressors: Who Comes Back?

Abstract

BackgroundPsychosocial evaluations to assess candidacy for advanced heart failure therapies are not standardized across institutions, potentially contributing to disparities in approval for advanced therapies. Remediation rates of psychosocial stressors among patients with advanced HF and reconsideration for advanced therapies have not been well described. Methods and ResultsWe performed a retrospective, single-center study of 647 adults evaluated for heart transplant and VAD between 2014 and 2020, of whom 89 (14%) were denied for psychosocial stressors including caregiver, substance use, housing, financial, or mental health concerns. Later reevaluation occurred in 32 (36%) patients, of whom 23 were then approved. Patients initially declined were mostly male (76%), white (74%), and urban (79%). Reevaluation occurred in more women than men (43% vs 34%), black patients than white (43% vs 37%), and urban patients than rural (39% vs 28%). Patients had fewer psychosocial stressors at reevaluation (median=0.5) than at initial denial (median=2). Caregiver and substance use concerns were the most prevalent stressors in patients never returning for or subsequently denied at reevaluation. ConclusionsCaregiver and substance use concerns were common in patients denied for psychosocial reasons. Future efforts should focus on early screening for these stressors and implementation of a systematic reevaluation process.