Primary Caregiver Relationships for Advanced Heart Failure Therapy Differ Based on Sex and Race and Predict Eligibility

Abstract

Introduction Use of heart transplant (HT) and left ventricular assist device (LVAD) are considered standard of care for eligible patients with end-stage heart failure (HF). In assessing eligibility, caregiver assistance is an important consideration in a patient's candidacy. While studies have shown that individuals without caregivers have worse survival outcomes, few studies have demonstrated how caregiver relationships differ based on sex and race, and whether that impacts eligibility for HT/LVAD. Hypothesis Women and Black patients are less likely than men and non-Black patients, respectively, to have a spouse listed as primary support, which may adversely affect eligibility for HT/LVAD. Methods We identified all patients (N=534) evaluated at Emory University for HT/LVAD from 2011 to 2016. Stanford Integrated Psychological Assessment for Transplant (SIPAT) scores were compared by sex and race using Wilcoxon rank-sum tests. The outcome of HT/LVAD evaluation according to primary caregiver relationship was compared by sex and race using X2 analysis. Multivariable logistic regression was used to determine the association between primary caregiver and HT/LVAD eligibility according to sex and race, adjusted for age, HF etiology, insurance, inotrope dependence, bilirubin, albumin, allosensitization, CKD stage, and SIPAT score. Results The mean age of the cohort was 52 ± 13 years; 171 (32%) were women and 294 (55%) were black. Total SIPAT scores did not vary significantly between men and women or blacks and non-blacks, regardless of primary support person. Women were less likely to have a spouse as primary support, and were more likely to have a parent or child as primary support (Table). Black patients were less likely to have a spouse as primary support, and were more likely to have a parent as primary support. In sex-stratified multivariable models, the choice of primary caregiver did not affect eligibility for HT/LVAD for women (P=0.8) or men (P=0.4). In race-stratified multivariable models, blacks with a parent as primary caregiver were less likely to be eligible for HT/LVAD (OR=0.17, 95% CI 0.03 - 0.97, P=0.04), however the primary caregiver was not associated with eligibility for HT/LVAD in non-black patients (P=0.9). Conclusion The choice of primary support person has a modest effect on decreasing eligibility for black patients being evaluated for advanced HF therapies, but not for women. More research is needed to determine unique barriers to advanced HF therapies for female and black patients.