Not By Choice: Black Patients With Advanced Heart Failure Are Less Likely To Receive A Vad Or Transplant Despite Their Preferences For Care

Abstract

<h3>Introduction</h3> Heart failure (HF) disproportionately affects marginalized people, including racial and ethnic minorities, and those impacted by social determinants of health (SDoH). Inequities in access to advanced therapies are well documented, though the reasons for such inequities remain uncertain. Potential explanations include access to care, patient preference, and biases in provider decision-making. <h3>Hypothesis</h3> Race and SDoH will impact utilization of advanced therapies, and patient preference for VAD will not modify the effect. <h3>Methods</h3> We performed an observational cohort study of Black and White ambulatory chronic systolic HF patients from 21 implanting VAD centers in The Registry Evaluation for Vital Information for VADs in Ambulatory Life (REVIVAL) study. Patients had ≥1 high-risk feature for death and no contraindication to VAD at enrollment. We performed competing events cause-specific proportional hazard models using multiple imputation for missing data with the primary outcomes of (1) death or (2) durable VAD/urgent transplant (TXP). Candidate variables included demographics (race, gender, age), SDoH (education, income, insurance type, caregiver), and four time-varying variables: clinician-assessed HF severity (INTERMACS Patient Profile), patient-reported quality of life (EuroQoL Visual Analogue Scale), preference for VAD given current health (3-point Likert scale), and "want for any and all life-sustaining therapies" (yes/no). <h3>Results</h3> The study included 377 participants, of whom 100 (26.5%) identified as Black. The primary outcomes of death and VAD/TXP occurred in 14.3% (n=54) and 19.4% (n=73) of patients. Preferences for VAD and life-sustaining therapies by race were similar. There was a non-significant increase in death among Black patients (HR, 95% CI; 1.23, 0.67-2.24), while Black race (0.46, 0.24-0.87) was associated with reduced utilization of VAD/TXP (Table). Preference for VAD or general life-sustaining therapies were not associated with either death or utilization of VAD/TXP. <h3>Conclusions</h3> Among patients receiving care by advanced heart failure cardiologists at VAD centers, there is less utilization of VAD/TXP for Black patients even after adjusting for HF severity, patient-reported QOL, SDoH, and despite similar patient preferences. This residual inequity in VAD and TXP may be a consequence of structural racism or result from provider bias or racism impacting clinician decision-making.