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Bechthold AC, McIlvennan CK, Matlock DD, Ejem DB, Wells RD, LeJeune J, Bakitas MA, Odom JN. "Things That You Thought Mattered, None of That Matters": A Qualitative Exploration of Family Caregiver Values following Left Ventricular Assist Device Implantation. J Cardiovasc Nurs 2024:00005082-990000000-00189. [PMID: 38786984 DOI: 10.1097/jcn.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Intentional exploration, or elicitation, of patient and family values-who/what matters most-is critical to the delivery of person-centered care, yet the values elicitation experiences of family caregivers have been understudied. Understanding caregiver experiences discussing, reflecting upon, and acting on their values is critical to optimizing health decisions after left ventricular assist device (LVAD) implantation. OBJECTIVE The aim of this study was to explore the values elicitation experiences of family caregivers of individuals with an LVAD in the postimplantation period. METHODS This was a qualitative descriptive study of LVAD caregivers recruited from an outpatient clinic in the southeast United States. After completing one-on-one semistructured interviews, participants' transcripts were analyzed using thematic analysis. RESULTS Interviewed caregivers (n = 21) were 27 to 76 years old, with 67% African American, 76% female, 76% urban-dwelling, and 62% a spouse/partner. LVAD implantation was an impactful experience prompting caregiver reevaluation of their values; these values became instrumental to navigating decisions and managing stressors from their caregiving role. Three broad themes of caregiver values elicitation experiences emerged: (1) caregivers leverage their values for strength and guidance in navigating their caregiving role, (2) LVAD implantation prompts (re)evaluation of relationships and priorities, and (3) caregivers convey their goals and priorities when deemed relevant to patient care. CONCLUSIONS Having a care recipient undergo LVAD implantation prompted caregivers to reevaluate their values, which were used to navigate caregiving decisions and stressors. Findings highlight the need for healthcare professionals to engage and support caregivers after LVAD implantation.
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Bechthold AC, McIlvennan CK, Matlock DD, Ejem DB, Wells RD, LeJeune J, Bakitas MA, Odom JN. "When I do have some time, rather than spend it polishing silver, I want to spend it with my grandkids": a qualitative exploration of patient values following left ventricular assist device implantation. BMC Palliat Care 2024; 23:128. [PMID: 38778297 PMCID: PMC11110360 DOI: 10.1186/s12904-024-01454-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Values are broadly understood to have implications for how individuals make decisions and cope with serious illness stressors, yet it remains uncertain how patients and their family and friend caregivers discuss, reflect upon, and act on their values in the post-left ventricular assist device (LVAD) implantation context. This study aimed to explore the values elicitation experiences of patients with an LVAD in the post-implantation period. METHODS Qualitative descriptive study of LVAD recipients. Socio-demographics and patient resource use were analyzed using descriptive statistics and semi-structured interview data using thematic analysis. Adult (> 18 years) patients with an LVAD receiving care at an outpatient clinic in the Southeastern United States. RESULTS Interviewed patients (n = 27) were 30-76 years, 59% male, 67% non-Hispanic Black, 70% married/living with a partner, and 70% urban-dwelling. Three broad themes of patient values elicitation experiences emerged: 1) LVAD implantation prompts deep reflection about life and what is important, 2) patient values are communicated in various circumstances to convey personal goals and priorities to caregivers and clinicians, and 3) patients leverage their values for strength and guidance in navigating life post-LVAD implantation. LVAD implantation was an impactful experience often leading to reevaluation of patients' values; these values became instrumental to making health decisions and coping with stressors during the post-LVAD implantation period. Patient values arose within broad, informal exchanges and focused, decision-making conversations with their caregiver and the healthcare team. CONCLUSIONS Clinicians should consider assessing the values of patients post-implantation to facilitate shared understanding of their goals/priorities and identify potential changes in their coping.
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Affiliation(s)
- Avery C Bechthold
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South NB 350, Birmingham, AL, 35294, USA.
| | - Colleen K McIlvennan
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Deborah B Ejem
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South NB 350, Birmingham, AL, 35294, USA
| | - Rachel D Wells
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South NB 350, Birmingham, AL, 35294, USA
| | - Jesse LeJeune
- Cardiology Clinic, UAB Hospital, Birmingham, AL, USA
| | - Marie A Bakitas
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South NB 350, Birmingham, AL, 35294, USA
| | - J Nicholas Odom
- School of Nursing, University of Alabama at Birmingham, 1720 2nd Avenue South NB 350, Birmingham, AL, 35294, USA
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Higgins RSD. Understanding the Persistent Impact of Social Determinants of Health on Aortic Surgery Outcomes: The Data Tell the Truth. Ann Thorac Surg 2024; 117:769. [PMID: 37302455 DOI: 10.1016/j.athoracsur.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Robert S D Higgins
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Office of the President, Ste PBB4-407, Boston, MA 02115.
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Preventza O, Akpan-Smart E, Lubna K, Simpson K, Cornwell L, Schmitt S, Amarasekara HS, LeMaire SA, Coselli JS. Racial disparities in thoracic aortic surgery: Myth or reality? J Thorac Cardiovasc Surg 2024; 167:3-12.e1. [PMID: 36549985 DOI: 10.1016/j.jtcvs.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/30/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We examined the relationship between Black or White race and adverse outcomes in patients who underwent surgery of the ascending aorta, aortic root, or aortic arch at our center. METHODS We analyzed 2335 consecutive patients who identified as Black (n = 217, 9.3%) or White (n = 2118, 90.7%) and underwent proximal aortic surgery. Patient zip codes were used to determine community socioeconomic (CSE) characteristics. The composite adverse outcome comprised mortality, persistent neurologic injury, and renal failure necessitating dialysis at discharge. We performed multivariable analysis, Kaplan-Meier analysis, and propensity score matching adjusted for CSE factors. RESULTS Median follow-up time was 3.7 years. Compared with White patients, Black patients lived in areas characterized by a higher percentage living below poverty level, lower income, and lower education level (P < .0001). Black patients had higher rates of emergency presentation (P < .0001) and lower 5- and 10-year survival rates (P = .0002). Short-term outcomes were similar between groups, except for respiratory failure and length of stay (P < .0001), which were higher in the Black population. After propensity score matching adjusted for CSE factors, Black and White patients (n = 204 each) had similar short-term outcomes and 5- and 10-year survival rates (P = .30). Multivariable analysis stratified by race showed that CSE factors independently predicted adverse outcomes in Black but not White patients. CONCLUSIONS This is among few studies that have analyzed the relationship between race and proximal aortic surgery. Although outcomes were similar between Black and White patients in our cohort after adjusting for CSE factors, unfavorable CSE factors predicted adverse outcomes in Black but not White patients. More patient-specific studies are needed.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | - Elizabeth Akpan-Smart
- Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Khan Lubna
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katherine Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Lorraine Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Sydney Schmitt
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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Steinberg RS, Okoh AK, Wang J, Patel KJ, Gangavelli A, Nayak A, Ko YA, Gupta D, Daneshmand M, Vega JD, Morris AA. Gender and Race Differences in HeartMate3 Left Ventricular Assist Device as a Bridge to Transplantation. JACC. HEART FAILURE 2023:S2213-1779(23)00760-6. [PMID: 38180429 DOI: 10.1016/j.jchf.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Gender and racial disparities exist after left ventricular assist device (LVAD) implantation. Compared with older devices, the HeartMate 3 (HM3) (Abbott Cardiovascular) has demonstrated improved survival. Whether HM3 differentially improves outcomes by gender or race and ethnic groups is unknown. OBJECTIVES The purpose of this study is to examine differences by gender and race in the use of HM3 among patients listed for heart transplantation (HT) and associated waitlist and post-transplant outcomes. METHODS The authors examined all patients (20% women, 33% Black) who received LVADs as bridge to transplantation (BTT) between January 2018 and June 2020, in the OPTN (Organ Procurement and Transplantation Network) database. Trends in use of HM3 were evaluated by gender and race. Competing events of death/delisting and transplantation were evaluated using subdistribution hazard models. Post-transplant outcomes were evaluated using multivariate logistic regression adjusted for demographic, clinical, and donor characteristics. RESULTS Of 11,524 patients listed for HT during the study period, 955 (8.3%) had HM3 implanted as BTT. Use of HM3 increased for all patients, with no difference in use by gender (P = 0.4) or by race (P = 0.2). Competing risk analysis did not demonstrate differences in transplantation or death/delisting in men compared with women (HT: adjusted HR [aHR]: 0.92 [95% CI: 0.70-1.21]; death/delisting: aHR: 0.91 [95% CI: 0.59-1.42]), although Black patients were transplanted fewer times than White patients (HT: aHR: 0.72 [95% CI: 0.57-0.91], death/delisting: aHR: 1.36 [95% CI: 0.98-1.89]). One-year post-transplant survival was comparable by gender (aHR: 0.52 [95% CI: 0.21-1.70]) and race (aHR: 0.76 [95% CI: 0.34-1.70]), with no differences in rates of stroke, acute rejection, or graft failure. CONCLUSIONS Use of HM3 among patients listed for HT has increased over time and by gender and race. Black patients with HM3 were less likely to be transplanted compared with White patients, but there were no differences in post-transplant outcomes between these groups or between men and women.
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Affiliation(s)
| | - Alexis K Okoh
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Jeffrey Wang
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Krishan J Patel
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Aditi Nayak
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi-An Ko
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Divya Gupta
- Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Mani Daneshmand
- Division of Surgery, Emory University, Atlanta, Georgia, USA
| | - J David Vega
- Division of Surgery, Emory University, Atlanta, Georgia, USA
| | - Alanna A Morris
- Division of Cardiology, Emory University, Atlanta, Georgia, USA.
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Matthews LJ, Damberg CL, Zhang S, Escarce JJ, Gibson CB, Schuler M, Popescu I. Within-Physician Differences in Patient Sharing Between Primary Care Physicians and Cardiologists Who Treat White and Black Patients With Heart Disease. J Am Heart Assoc 2023; 12:e030653. [PMID: 37982233 PMCID: PMC10727292 DOI: 10.1161/jaha.123.030653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Black-White disparities in heart disease treatment may be attributable to differences in physician referral networks. We mapped physician networks for Medicare patients and examined within-physician Black-White differences in patient sharing between primary care physicians and cardiologists. METHODS AND RESULTS Using Medicare fee-for-service files for 2016 to 2017, we identified a cohort of Black and White patients with heart disease and the primary care physicians and cardiologists treating them. To ensure the robustness of within-physician comparisons, we restricted the sample to regional health care markets (ie, hospital referral regions) with at least 10 physicians sharing ≥3 Black and White patients. We used claims to construct 2 race-specific physician network measures: degree (number of cardiologists with whom a primary care physician shares patients) and transitivity (network tightness). Measures were adjusted for Black-White differences in physician panel size and calculated for all settings (hospital and office) and for office settings only. Of 306 US hospital referral regions, 226 and 145 met study criteria for all settings and office setting analyses, respectively. Black patients had more cardiology encounters overall (6.9 versus 6.6; P<0.001) and with unique cardiologists (3.0 versus 2.6; P<0.001), but fewer office encounters (31.7% versus 41.1%; P<0.001). Primary care physicians shared Black patients with more cardiologists than White patients (mean differential degree 23.4 for all settings and 3.6 for office analyses; P<0.001 for both). Black patient-sharing networks were less tightly connected in all but office settings (mean differential transitivity -0.2 for all settings [P<0.001] and near 0 for office analyses [P=0.74]). CONCLUSIONS Within-physician Black-White differences in patient sharing exist and may contribute to disparities in cardiac care.
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Affiliation(s)
| | | | | | | | | | | | - Ioana Popescu
- RAND CorporationSanta MonicaCA
- David Geffen School of Medicine at UCLALos AngelesCA
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7
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Fox DK, Waken RJ, Wang F, Wolfe JD, Robbins K, Fanous E, Vader JM, Schilling JD, Joynt Maddox KE. The Association of the UNOS Heart Allocation Policy Change With Transplant and Left Ventricular Assist Device Access and Outcomes. Am J Cardiol 2023; 204:392-400. [PMID: 37586314 PMCID: PMC10950424 DOI: 10.1016/j.amjcard.2023.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023]
Abstract
In October 2018, the allocation policy for adult orthotopic heart transplant (OHTx) in the United States was changed, with the goal of reducing waitlist mortality and providing broader sharing of donor organs within the United States. This study aimed to assess the association of this policy change with changes in access to OHTx versus left ventricular assist devices (LVADs), overall and in key sociodemographic subgroups, in the United States from 2016 to 2019. We identified all patients receiving OHTx or LVAD between 2016 and 2019 using the National Inpatient Sample. Controlling for medical co-morbidities, prepolicy trends, and within-hospital-year effects, we fit a dynamic logistic regression model to evaluate patient and hospital factors associated with receiving OHTx versus LVAD before versus after policy change. We also examined the frequency of temporary mechanical circulatory support in the same fashion. We identified 2,264 patients who received OHTx and 3,157 who received LVADs during the study period. In its first year of implementation, the United Network for Organ Sharing policy change of 2018 was associated with no overall change utilization of OHTx versus LVAD. In OHTx recipients, the frequency of use of temporary mechanical circulatory support changed from 15.6% in the before period to 42.6% in the after period (p <0.001). Although the policy change was associated with differences in the odds of receiving an OHTx versus LVAD between different regions of the country, there were no significant changes based on age, gender, race/ethnicity, insurance status, or rurality. In conclusion, the United Network for Organ Sharing policy change on access to OHTx was associated with no overall change in OHTx versus LVAD use in its first year of implementation although we observed small changes in relative odds of transplant based on rurality. Shifts in regional allocation were not significant overall, although certain regions appeared to have a relative increase in their use of OHTx.
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Affiliation(s)
- Daniel K Fox
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - R J Waken
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis
| | - Fengxian Wang
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis
| | - Jonathan D Wolfe
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Keenan Robbins
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Erika Fanous
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Vader
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Joel D Schilling
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis.
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Suarez-Pierre A, Iguidbashian J, Kirsch MJ, Cotton JL, Quinn C, Fullerton DA, Reece TB, Hoffman JRH, Cleveland JC, Rove JY. Importance of social vulnerability on long-term outcomes after heart transplantation. Am J Transplant 2023; 23:1580-1589. [PMID: 37414250 DOI: 10.1016/j.ajt.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/25/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
The relationship between social determinants of health and outcomes after heart transplantation has not been examined. The social vulnerability index (SVI) uses United States census data to determine the social vulnerability of every census tract based on 15 factors. This retrospective study seeks to examine the impact of SVI on outcomes after heart transplantation. Adult heart recipients who received a graft between 2012 and 2021 were stratified into SVI percentiles of <75% and SVI of ≥75%. The primary endpoint was survival. The median SVI was 48% (interquartile range: 30%-67%) among 23 700 recipients. One-year survival was similar between groups (91.4 vs 90.7%, log-rank P = .169); however, 5-year survival was lower among individuals living in vulnerable communities (74.8% vs 80.0%, P < .001). This finding persisted despite risk adjustment for other factors associated with mortality (survival time ratio 0.819, 95% confidence interval: 0.755-0.890, P < .001). The incidences of 5-year hospital readmission (81.4% vs 75.4%, P < .001) and graft rejection (40.3% vs 35.7%, P = .004) were higher among individuals living in vulnerable communities. Individuals living in vulnerable communities may be at increased risk of mortality after heart transplantation. These findings suggest there is an opportunity to focus on these recipients undergoing heart transplantation to improve survival.
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Affiliation(s)
- Alejandro Suarez-Pierre
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - John Iguidbashian
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J Kirsch
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jake L Cotton
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christopher Quinn
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David A Fullerton
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Thomas Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
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Rekhtman D, Iyengar A, Song C, Weingarten N, Shin M, Patel M, Herbst DA, Helmers M, Cevasco M, Atluri P. Emerging Racial Differences in Heart Transplant Waitlist Outcomes for Patients on Temporary Mechanical Circulatory Support. Am J Cardiol 2023; 204:234-241. [PMID: 37556892 DOI: 10.1016/j.amjcard.2023.07.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023]
Abstract
Temporary mechanical circulatory support (tMCS) is increasingly used for patients awaiting heart transplantation. Although examples of systemic inequity in cardiac care have been described, biases in tMCS use are not well characterized. This study explores the racial disparities in tMCS use and waitlist outcomes. The United Network for Organ Sharing database was used to identify adults listed for first-time heart transplantation from 2015 to 2021. White and non-White patients on extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary left ventricular assist device were identified. Waitlist outcomes of mortality, transplantation, and delisting were analyzed by race using competing risks regression. The effect of the new heart allocation system was also assessed. A total of 16,811 patients were included in this study, with 10,377 self-identifying as White and 6,434 as non-White. White patients were more often male, privately ensured, and had less co-morbidities (p <0.05). tMCS use was found to be significantly higher in non-White patients (p <0.001). Among those on tMCS, non-White patients were more likely to be delisted because of illness (subhazard ratio 1.34 [1.09 to 1.63]) and less likely to die while on the waitlist (subhazard ratio 0.76 [0.61 to 0.93]). This disparity was not present before the implementation of the new heart allocation system. tMCS use was proportional to the risk factors identified in the non-White cohort. After the implementation of the new heart allocation system, White patients were more likely to die, whereas non-White patients were more likely to be delisted. Further work is needed to determine the causes of and potential solutions for disparities in the waitlist outcomes.
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Affiliation(s)
- David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mrinal Patel
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Alan Herbst
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Helmers
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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10
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Sherazi S, Alexis JD, McNitt S, Polonsky B, Shah S, Younis A, Kutyifa V, Vidula H, Gosev I, Goldenberg I. Racial differences in clinical characteristics and readmission burden among patients with a left ventricular-assist device. Artif Organs 2023; 47:1242-1249. [PMID: 36820756 DOI: 10.1111/aor.14506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND There are limited data regarding racial disparities in outcomes after left ventricular assist device (LVAD) implantation. The purpose of this study was to compare clinical characteristics and the burden of readmissions by race among patients with LVAD. METHODS The study population included 461 patients implanted with LVADs at the University of Rochester Medical Center, NY from May 2008 to March 2020. Patients were stratified by race as White patients (N = 396 [86%]) and Black patients (N = 65 [14%]). The Anderson-Gill recurrent regression analysis was used to assess the independent association between race and the total number of admissions after LVAD implant during an average follow-up of 2.45 ± 2.30 years. RESULTS Black patients displayed significant differences in baseline clinical characteristics compared to White patients, including a younger age, a lower frequency of ischemic etiology, and a higher baseline serum creatinine. Black patients had a significantly higher burden of readmissions after LVAD implantation as compared with White patients 10 versus 7 (average number of hospitalizations per patient at 5 years of follow-up, respectively) translated into a significant 39% increased risk of recurrent readmissions after multivariate adjustment (Hazard ratio 1.39, 95% CI; 1.07-1.82, p 0.013). CONCLUSION Black LVAD patients experience an increased burden of readmissions compared with White patients, after adjustment for baseline differences in demographics and clinical characteristics. Future studies should assess the underlying mechanisms for this increased risk including the effect of social determinants of health on the risk of readmissions in LVAD recipients.
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Affiliation(s)
- Saadia Sherazi
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jeffrey D Alexis
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Bronislava Polonsky
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Suhaib Shah
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Arwa Younis
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Valentina Kutyifa
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Himabindu Vidula
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Igor Gosev
- Division of Cardiothoracic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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11
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Shetty NS, Parcha V, Abdelmessih P, Patel N, Hasnie AA, Kalra R, Pandey A, Breathett K, Morris AA, Arora G, Arora P. Sex-Associated Differences in the Clinical Outcomes of Left Ventricular Assist Device Recipients: Insights From Interagency Registry for Mechanically Assisted Circulatory Support. Circ Heart Fail 2023; 16:e010189. [PMID: 37232167 PMCID: PMC10421565 DOI: 10.1161/circheartfailure.122.010189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/20/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sex-associated differences in clinical outcomes among left ventricular assist device recipients in the United States have been recognized. However, an investigation of the social and clinical determinants of sex-associated differences is lacking. METHODS Left ventricular assist device receiving patients enrolled in Interagency Registry for Mechanically Assisted Circulatory Support between 2005 and 2017 were included. The primary outcome was all-cause mortality. Secondary outcomes included heart transplantation and postimplantation adverse event rates. The cohort was stratified by the social subgroup of race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic), and clinical subgroups of device strategy (destination therapy, bridge to transplant, and bridge to candidacy), and implantation center volume (low [≤20 implants/y], medium [21-30 implants/y], and high [>30 implants/y]). A multivariable-adjusted Cox proportional hazard model was used to assess the risk of death and heart transplantation with prespecified interaction testing. Poisson regression was used to estimate adverse events by sex across the various subgroups. RESULTS Among 18 525 patients, there were 3968 (21.4%) females. Compared with their male counterparts, Hispanic (adjusted hazard ratio [HRadj], 1.75 [1.23-2.47]) females had the highest risk of death followed by non-Hispanic White females (HRadj, 1.15 [1.07-1.25]; Pinteraction=0.02). Hispanic (HRadj, 0.60 [0.40-0.89]) females had the lowest cumulative incidence of heart transplantation followed by non-Hispanic Black females (HRadj, 0.76 [0.67-0.86]), and non-Hispanic White females (HRadj, 0.88 [0.80-0.96]) compared with their male counterparts (Pinteraction<0.001). Compared with their male counterparts, females on the bridge to candidacy strategy (HRadj, 1.32 [1.18-1.48]) had the highest risk of death (Pinteraction=0.01). The risk of death (Pinteraction=0.44) and cumulative incidence of heart transplantation (Pinteraction=0.40) did not vary by sex in the center volume subgroup. A higher incidence rate of adverse events after left ventricular assist device implantation was also seen in females compared with the males, overall, and across all subgroups. CONCLUSIONS Among left ventricular assist device recipients, the risk of death, the cumulative incidence of heart transplantation, and adverse events differ by sex across the social and clinical subgroups.
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Affiliation(s)
- Naman S. Shetty
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vibhu Parcha
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Abdelmessih
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nirav Patel
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ammar A. Hasnie
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Khadijah Breathett
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alanna A. Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Garima Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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12
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Amdani S, Conway J, Kleinmahon J, Auerbach S, Hsu D, Cousino MK, Kaufman B, Alejos J, Cruz JH, Lee HY, Rudraraju R, Kirklin JK, Asante-Korang A. Race and Socioeconomic Bias in Pediatric Cardiac Transplantation. JACC. HEART FAILURE 2023; 11:19-26. [PMID: 36599545 DOI: 10.1016/j.jchf.2022.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND To date, no studies evaluated implicit bias among clinicians caring for children with advanced heart failure. OBJECTIVES This study aims to evaluate implicit racial and socioeconomic bias among pediatric heart transplant clinicians. METHODS A cross-sectional survey of transplant clinicians from the Pediatric Heart Transplant Society was conducted between June and August 2021. The survey consisted of demographic questions along with explicit and validated race and socioeconomic status (SES) implicit association tests (IATs). Implicit and explicit biases among survey group members were studied and associations were tested between implicit and explicit measures. RESULTS Of 500 members, 91 (18.2%) individuals completed the race IAT and 70 (14%) completed the SES IAT. Race IAT scores indicated moderate levels of implicit bias (mean = 0.33, d = 0.76; P < 0.001; ie, preference for White individuals). SES IAT scores indicated strong implicit bias (mean = 0.52, d = 1.53; P < 0.001; ie, preference for people from upper SES). There were weak levels of explicit race and wealth bias. There was a strong level of explicit education bias (mean = 5.22, d = 1.19; P < 0.001; ie, preference for educated people). There were nonsignificant correlations between the race and the SES IAT and explicit measures (P > 0.05 for all). CONCLUSIONS As observed across other health care disciplines, among a group of pediatric heart transplant clinicians, there is an implicit preference for individuals who are White and from higher SES, and an explicit preference for educated people. Future studies should evaluate how implicit biases affect clinician behavior and assess the impact of efforts to reduce such biases.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA.
| | - Jennifer Conway
- Department of Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jake Kleinmahon
- Department of Cardiology, Ochsner Hospital for Children, New Orleans, Louisiana, USA
| | - Scott Auerbach
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Daphne Hsu
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, Bronx, New York, USA
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Beth Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Stanford, California, USA
| | - Juan Alejos
- Division of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Jason Hopper Cruz
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Hannah Y Lee
- Department of Pediatrics, Program for Pediatric Cardiomyopathy, Heart Failure and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Ramaraju Rudraraju
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alfred Asante-Korang
- Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
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13
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 623] [Impact Index Per Article: 311.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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14
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 730] [Impact Index Per Article: 365.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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15
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Amiya E. Social Inequalities in Non-ischemic Cardiomyopathies. Front Cardiovasc Med 2022; 9:831918. [PMID: 35321101 PMCID: PMC8934878 DOI: 10.3389/fcvm.2022.831918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Heart failure (HF) has various characteristics, such as etiology, clinical course, and clinical characteristics. Several studies reported the clinical findings of the characteristics of non-ischemic cardiomyopathy. There have been issues with genetic, biochemical, or pathophysiological problems. Some studies have been conducted on non-ischemic cardiomyopathy and social factors, for instance, racial disparities in peripartum cardiomyopathy (PPCM) or the social setting of hypertrophic cardiomyopathy. However, there have been insufficient materials to consider the relationship between social factors and clinical course in non-ischemic cardiomyopathies. There were various methodologies in therapeutic interventions, such as pharmacological, surgical, or rehabilitational, and educational issues. However, interventions that could be closely associated with social inequality have not been sufficiently elucidated. We will summarize the effects of social equality, which could have a large impact on the development and progression of HF in non-ischemic cardiomyopathies.
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Affiliation(s)
- Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Therapeutic Strategy for Heart Failure, University of Tokyo, Tokyo, Japan
- *Correspondence: Eisuke Amiya
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16
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Kostick-Quenet KM, Cohen IG, Gerke S, Lo B, Antaki J, Movahedi F, Njah H, Schoen L, Estep JE, Blumenthal-Barby JS. Mitigating Racial Bias in Machine Learning. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2022; 50:92-100. [PMID: 35243993 DOI: 10.1017/jme.2022.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
When applied in the health sector, AI-based applications raise not only ethical but legal and safety concerns, where algorithms trained on data from majority populations can generate less accurate or reliable results for minorities and other disadvantaged groups.
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17
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Ntusi NAB, Sliwa K. Impact of Racial and Ethnic Disparities on Patients With Dilated Cardiomyopathy: JACC Focus Seminar 7/9. J Am Coll Cardiol 2021; 78:2580-2588. [PMID: 34887144 DOI: 10.1016/j.jacc.2021.10.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/29/2021] [Accepted: 10/05/2021] [Indexed: 10/19/2022]
Abstract
Significant race- and ethnicity-based disparities among those diagnosed with dilated cardiomyopathy (DCM) exist and are deeply rooted in the history of many societies. The role of social determinants of racial disparities, including racism and bias, is often overlooked in cardiology. DCM incidence is higher in Black subjects; survival and other outcome measures are worse in Black patients with DCM, with fewer referrals for transplantation. DCM in Black patients is underrecognized and under-referred for effective therapies, a consequence of a complex interplay of social and socioeconomic factors. Strategies to manage social determinants of health must be multifaceted and consider changes in policy to expand access to equitable care; provision of insurance, education, and housing; and addressing racism and bias in health care workers. There is an urgent need to prioritize a social justice approach to health care and the pursuit of health equity to eliminate race and other disparities in the management of cardiovascular disease.
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Affiliation(s)
- Ntobeko A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa; Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Cape Universities Body Imaging Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa; Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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18
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Lewsey SC, Breathett K. Equity in Heart Transplant Allocation: Intended Progress Up the Hill or an Impossibility? J Am Heart Assoc 2021; 10:e022817. [PMID: 34431374 PMCID: PMC8649239 DOI: 10.1161/jaha.121.022817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Sabra C Lewsey
- Division of Cardiology Johns Hopkins University School of Medicine Baltimore MD
| | - Khadijah Breathett
- Division of Cardiology Sarver Heart Center University of Arizona Tucson AZ
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19
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de la Rosa AL, Singer-Englar T, Tompkins RO, Patel JK, Kobashigawa JA, Kittleson MM. Advanced heart failure and heart transplantation in adult congenital heart disease in the current era. Clin Transplant 2021; 35:e14451. [PMID: 34365682 DOI: 10.1111/ctr.14451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) may undergo heart transplantation (HTx) despite increased risk of poor short-term outcomes due to factors including surgical complexity and antibody sensitization. We assessed the clinical characteristics and outcomes of patients with ACHD in the current era referred for HTx at a single high-volume transplant center. METHODS From 2010-2020, 37 ACHD patients were evaluated for HTx. ACHD HTx recipients were compared to non-ACHD HTx recipients matched for age, sex, listing status, and prior cardiac surgery. RESULTS Of the 37 patients with ACHD, 8 (21.6%) were declined for HTx. Of 29 ACHD patients listed, 19 (65.5%) underwent HTx. Compared with non-ACHD HTx controls, the ACHD HTx recipients had more treated cellular (21.1% vs 15.8%, p = 0.010) and antibody-mediated (15.8% vs 10.5%, p = 0.033) rejection. There was no difference in hospital readmission or allograft vasculopathy at 1 year. There was a nonsignificant higher 1-year mortality in ACHD HTx recipients (21.1% vs 7.9%, p = 0.21). CONCLUSION At a high-volume transplant center, ACHD patients undergoing HTx appear to have a marginally higher risk of rejection, but no significant increase in 1-year mortality. With careful selection and management, HTx for patients with ACHD may be feasible in the current era. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Angelo L de la Rosa
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tahli Singer-Englar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rose O Tompkins
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jignesh K Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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20
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Abstract
PURPOSE OF REVIEW Despite attention to racial disparities in outcomes for heart failure (HF) and other chronic diseases, progress against these inequities has been gradual at best. The disparities of COVID-19 and police brutality have highlighted the pervasiveness of systemic racism in health outcomes. Whether racial bias impacts patient access to advanced HF therapies is unclear. RECENT FINDINGS As documented in other settings, racial bias appears to operate in HF providers' consideration of patients for advanced therapy. Multiple medical and psychosocial elements of the evaluation process are particularly vulnerable to bias. SUMMARY Reducing gaps in access to advanced therapies will require commitments at multiple levels to reduce barriers to healthcare access, standardize clinical operations, research the determinants of patient success and increase diversity among providers and researchers. Progress is achievable but likely requires as disruptive and investment of immense resources as in the battle against COVID-19.
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Affiliation(s)
- Raymond C Givens
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
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21
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Abstract
PURPOSE OF REVIEW This review discusses the current state of racial and ethnic inequities in heart failure burden, outcomes, and management. This review also frames considerations for bridging disparities to optimize quality heart failure care across diverse communities. RECENT FINDINGS Treatment options for heart failure have diversified and overall heart failure survival has improved with the advent of effective pharmacologic and nonpharmacologic therapies. With increased recognition, some racial/ethnic disparity gaps have narrowed whereas others in heart failure outcomes, utilization of therapies, and advanced therapy access persist or worsen. SUMMARY Racial and ethnic minorities have the highest incidence, prevalence, and hospitalization rates from heart failure. In spite of improved therapies and overall survival, the mortality disparity gap in African American patients has widened over time. Racial/ethnic inequities in access to cardiovascular care, utilization of efficacious guideline-directed heart failure therapies, and allocation of advanced therapies may contribute to disparate outcomes. Strategic and earnest interventions considering social and structural determinants of health are critically needed to bridge racial/ethnic disparities, increase dissemination, and implementation of preventive and therapeutic measures, and collectively improve the health and longevity of patients with heart failure.
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Affiliation(s)
- Sabra C. Lewsey
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ
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22
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Abstract
PURPOSE OF REVIEW The aim of this review is to discuss racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure (ADHF). RECENT FINDINGS Race and sex have a significant impact on in-hospital admissions and overall outcomes in patients with decompensated heart failure and cardiogenic shock. Black patients not only have a higher incidence of heart failure than other racial groups, but also higher admissions for ADHF and worse overall survival, while women receive less interventions for cardiogenic shock complicating acute myocardial infarction. Moreover, White patients are more likely than Black patients to be cared for by a cardiologist than a noncardiologist in the ICU, which has been linked to overall improved survival. In addition, recent data outline inherent racial and sex bias in the evaluation process for advanced heart failure therapies indicating that Black race negatively impacts referral for transplant, women are judged more harshly on their appearance, and that Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies. SUMMARY Though significant racial and sex disparities exist in the management and treatment of patients with decompensated heart failure, these disparities are minimized when therapies are properly utilized and patients are treated according to guidelines.
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23
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Abstract
PURPOSE OF REVIEW Despite advances in medical and device-based therapies for advanced heart failure as well as public policy, disparities by race/ethnicity persist in heart failure clinical outcomes. The purpose of this review is to describe disparities in outcomes by race--ethnicity in patients after receipt of heart transplantation and left ventricular assist device (LVAD), and the current understanding of factors contributing to these disparities. RECENT FINDINGS The proportion of black and Latinx patients receiving advanced heart failure therapies continues to rise, and they have worse hemodynamic profiles at the time of referral for heart transplantation and LVAD. Black patients have lower rates of survival after heart transplantation, in part because of higher rates of cellular and humoral rejection that may be mediated through unique gene pathways, and increased risk for allosensitization and de-novo donor-specific antibodies. Factors that have previously been cited as reasons for worse outcomes in race--ethnic minorities, including psychosocial risk and lower SES, may not be as strongly correlated with outcomes after LVAD. SUMMARY Black and Latinx patients are sicker at the time of referral for advanced heart failure therapies. Despite higher psychosocial risk factors among race--ethnic minorities, outcomes after LVAD appear to be similar to white patients. Black patients continue to have lower posttransplant survival, because of a complex interplay of immunologic susceptibility, clinical and socioeconomic factors. No single factor accounts for the disparities in clinical outcomes for race--ethnic minorities, and thus consideration of these components together is critical in management of these patients.
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24
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Frech A, Tarrence J, Natale G, Tumin D. Ventricular Assist Device Technology and Black-White Disparities on the Heart Transplant Wait List. Prog Transplant 2020; 31:80-87. [DOI: 10.1177/1526924820978591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Heart transplantation is the definitive treatment for end-stage heart failure. Left ventricular assist devices (LVADs) are a continually improving technology that extends life for some candidates on the heart transplant waiting list. Research Questions: Our objective is to compare Black-White differences in LVAD implantation and heart transplant outcomes during a period of technological innovation when the pulsatile flow LVAD was largely replaced by the continuous flow LVAD between 1999-2014. Design: We used transplant registry data from the United Network for Organ Sharing (N = 5,550) to identify Black and White patients with heart failure who used an LVAD as a bridge-to-transplant (BTT). Using logistic regression, we compared Black-White differences in access to newer LVAD technology and timing of implantation relative to wait listing for heart transplantation. We used competing-risks event history models to predict transplant outcomes across race, LVAD type, and timing of LVAD implantation. Results: Black and White candidates were equally likely to receive newer continuous flow LVADs, but Black candidates received LVADs later in the disease course (i.e. after transplant listing). This later timing of technological intervention contributed to poorer wait list outcomes among black transplant candidates, including lower likelihood of receiving a heart transplant and greater likelihood of being removed from the wait list due to worsening health. Discussion: Delayed LVAD implantation is more common among Black patients and is associated with poorer transplant outcomes.
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Affiliation(s)
- Adrianne Frech
- Department of Health Sciences, University of Missouri, Columbia, MO, USA
| | - Jake Tarrence
- Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Ginny Natale
- Program on Public Health, Stony Brook University, Stony Brook, NY, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA
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25
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Bayne J, Francke M, Ma E, Rubin GA, Avula UMR, Baksh H, Givens R, Wan EY. Increased Incidence of Chronic Kidney Injury in African Americans Following Cardiac Transplantation. J Racial Ethn Health Disparities 2020; 8:1435-1446. [PMID: 33113077 DOI: 10.1007/s40615-020-00906-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES This study examined whether African American race was associated with an elevated risk of chronic kidney disease (CKD) post-cardiac transplantation. BACKGROUND CKD often occurs after cardiac transplantation and may require renal replacement therapy (RRT) or renal transplant. African American patients have a higher risk for kidney disease as well as worse post-cardiac transplant morbidity and mortality. It is unclear, however, if there is a propensity for African Americans to develop CKD after cardiac transplant. METHODS The Institutional Review Board of Columbia University Medical Center approved the retrospective study of 151 adults (57 African American and 94 non-African American) who underwent single-organ heart transplant from 2013 to 2016. The primary outcome was a decrease in estimated glomerular filtration rate (eGFR), development of CKD, and end-stage renal disease (ESRD) requiring RRT after 2 years. RESULTS African American patients had a significant decline in eGFR post-cardiac transplant compared to non-African American patients (- 34 ± 6 vs. - 20 ± 4 mL/min/1.73 m2, p < 0.0006). African American patients were more likely to develop CKD stage 2 or worse (eGFR < 90 mL/min/1.73 m2) than non-African American patients (81% vs. 59%, p < 0.0005). CONCLUSIONS This is the first study to report that African American patients are at a significantly higher risk for eGFR decline and CKD at 2 years post-cardiac transplant. Future investigation into risk reduction is necessary for this patient population.
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Affiliation(s)
- Joseph Bayne
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Michael Francke
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Elaine Ma
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Geoffrey A Rubin
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Uma Mahesh R Avula
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Haajra Baksh
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Raymond Givens
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 622 W168 Street, PH 3-Center, New York, NY, 10032, USA.
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Ueyama H, Malik A, Kuno T, Yokoyama Y, Briasouli A, Shetty S, Briasoulis A. Racial disparities in in-hospital outcomes after left ventricular assist device implantation. J Card Surg 2020; 35:2633-2639. [PMID: 32667085 DOI: 10.1111/jocs.14859] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous studies of patients undergoing various cardiac surgeries demonstrated worse outcomes among African-American (AA) patients. It remains unclear if the race is a predictor of outcomes among left ventricular assist device (LVAD) recipients. METHODS Patients who underwent LVAD implantation between 2010 and 2017 were identified using the National Inpatient Sample. The race was classified as Caucasians vs AA vs Hispanics, and endpoints were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via the International Classification of Diseases-9 (ICD-9) and ICD-10 coding and analysis performed via mixed-effect models. RESULTS A total of 27 132 adults (5114 unweighted) underwent LVAD implantation in the U.S. between 2010 and 2017, including Caucasians (63.8%), AA (23.8%), and Hispanics (6%). The number of LVAD implantations increased in both Caucasians and AA during the study period. AA LVAD recipients were younger, with higher rates of females and mostly comorbidities, but lower rates of coronary artery disease and bypass grafting compared to Caucasians and Hispanics. Medicaid and median income at the lowest quartile were more frequent among AA LVAD recipients. We did not identify differences in stroke, bleeding complications, tamponade, infectious complications, acute kidney injury requiring hemodialysis, and in-hospital mortality among racial groups. AA LVAD recipients had lower rates of routine discharge than Caucasians and Hispanics, longer length of stay than Caucasians, but similar cost of hospitalization. After adjustment for clinical comorbidities, race was not a predictor of in-hospital mortality. CONCLUSION We identified differences in clinical characteristics but not in in-hospital complications among LVAD recipients of a different races.
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Affiliation(s)
- Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel, New York City, New York
| | - Aaqib Malik
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine, Mount Sinai Beth Israel, New York City, New York
| | - Yujiro Yokoyama
- Department of Surgery, Easton Hospital, Easton, Pennsylvania
| | - Artemis Briasouli
- Section of Heart Failure and Transplantation, Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Suchith Shetty
- Section of Heart Failure and Transplantation, Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Alexandros Briasoulis
- Section of Heart Failure and Transplantation, Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
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Okoh AK, Selevanny M, Singh S, Hirji S, Singh S, Al Obaidi N, Lee LY, Camacho M, Russo MJ. Racial disparities and outcomes of left ventricular assist device implantation as a bridge to heart transplantation. ESC Heart Fail 2020; 7:2744-2751. [PMID: 32627939 PMCID: PMC7524221 DOI: 10.1002/ehf2.12866] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/27/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
Aims This study investigated outcomes after continuous flow left ventricular assist device (CF‐LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race. Methods and results De‐identified data from the United Network for Organ Sharing database was obtained for all patients who had a CF‐LVAD as BTT from 2008 to 2018. Patients were stratified into four groups on the basis of ethnicity [Caucasian, African American (AA), Hispanic, and others (Asian, Pacific Islanders, and American Indian)]. Outcomes investigated were waitlist mortality or delisting and post‐transplant 5 year survival. Cox proportional hazards modelling was used to identify independent predictors of waitlist mortality or delisting and post‐transplant survival. We used Kaplan–Meier survival curves and the log‐rank test to estimate and compare survival among groups. A total of 14 234 patients who had CF‐LVADs as BTT were identified. Of these, 64% (n = 9058) were Caucasians, 26% (n = 3677) were AA, 7% (n = 997) were Hispanic, and 3% (n = 502) had a different race. Compared with Caucasian, AA, and Hispanic patients had higher body mass indexes and a lower level of education and are more likely to be public health insurance beneficiaries. There was a significantly lower incidence of transplantation in AAs compared with Caucasians, Hispanics, and others at 12, 24, and 60 months, respectively (Gray's test, P < 0.001). The AA race was a significant predictor of waitlist mortality or delisting owing to worsening clinical status [hazard ratio, 95% confidence interval: 1.10 (1.01 to 1.16; P < 0.001)]. Among those who were successfully BTT, risk‐adjusted post‐transplant survival was similar among the four groups (log‐rank test: P = 0.589). Conclusions Disparities exist among different races that receive a CF‐LVAD as a BTT. These disparities translate into increased waitlist morbidity and mortality but not long‐term post‐transplant survival among those who successfully reach transplant.
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Affiliation(s)
- Alexis Kofi Okoh
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA.,Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Mariam Selevanny
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Supreet Singh
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Sameer Hirji
- Department of Surgery, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Swaiman Singh
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Nawar Al Obaidi
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA
| | - Leonard Y Lee
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Margarita Camacho
- Cardiovascular Research Unit, RWJ Barnabas Health Heart Centers, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite G5, Newark, NJ, USA.,Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Mark J Russo
- Department of Surgery, Division of Cardiac Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Affiliation(s)
- Bessie A Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Hospital and Specialty Medicine and Seattle Health Services Research and Development Center of Innovation for Veteran-Centered and Veteran-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Okoh AK, Singh S, Hirji S. Bridging the Disparities Gap to Heart Transplantation With Left Ventricular Assist Devices. Ann Thorac Surg 2020; 110:754-756. [PMID: 32006476 DOI: 10.1016/j.athoracsur.2019.12.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/07/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Alexis K Okoh
- Cardiovascular Outcomes Research Unit, RWJ Barnabas Health, Newark Beth Isreal Medical Center, 201 Lyons Ave, Ste G5, Newark, NJ 07112.
| | - Supreet Singh
- Cardiovascular Outcomes Research Unit, RWJ Barnabas Health, Newark Beth Isreal Medical Center, Newark, New Jersey
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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