Disparity in Use of Left Ventricular Assist Devices among African American Patients with Medicare

Abstract

Purpose Heart failure (HF) disproportionally affects racial minorities and disparities in access to therapies exist. Recent work suggests greater use of left ventricular assist devices (LVAD) among African American (AA) patients compared to white patients that likely remains disparate due to a higher prevalence of HF in AA. We sought to understand disparities in LVAD use by race among a cohort of patients with similar HF severity and explore the impact of socioeconomic disadvantage. Methods We analyzed fee-for-service Medicare claims among 311,265 beneficiaries admitted with a principal diagnosis of systolic HF between 2008-2014. Inpatient and outpatient claims in prior 6 months used to estimate propensity for LVAD treatment using synthetic minority over-sampling, a machine learning method. Beneficiaries with ≥70% predicted probability of receiving an LVAD were included. These results were applied to model disparities using logistic regression with LVAD use and 1-year survival with and without LVAD among AA and white recipients as the dependent variables. Model covariates included race, clinical characteristics, distance from LVAD center, and year. After confirming a disparity, the Medicare low-income subsidy included to explore impact of socioeconomic disadvantage. Results The sample included 15,406 observations, of whom 45.2% (n=6,967) received an LVAD. AA were 23.6% (n=3,648) of the population and 21.8% (n=1,520) of LVAD recipients. One-year survival was 73% with LVAD and 62% without. Compared to white patients, AA patients matched for the propensity to receive an LVAD were 4.0% less likely to receive the therapy (95% CI -5.1 to -1.7; p Conclusion Disparities in the use of LVAD for AA Medicare beneficiaries with HF exist that are not entirely explained by socioeconomic disadvantage. These data suggest that other factors are impacting the application of LVAD therapy in AA patients. Potential explanations include racial biases or systemic racism that influence clinician decision-making or patient preferences.