Association of race and gender with primary caregiver relationships and eligibility for advanced heart failure therapies

Sex and Gender-related Disparities in Clinical Characteristics and Outcomes in Heart Transplantation

PURPOSE OF REVIEW

Limited research has been conducted on sex disparities in heart transplant (HT). The aim of this review is to analyse the available evidence on the influence of sex and gender-related determinants in the entire HT process, as well as to identify areas for further investigation.

RECENT FINDINGS

Although women make up half of the population affected by heart failure and related mortality, they account for less than a third of HT recipients. Reasons for this inequality include differences in disease course, psychosocial factors, concerns about allosensitisation, and selection or referral bias in female patients. Women are more often listed for HT due to non-ischaemic cardiomyopathy and have a lower burden of cardiovascular risk factors. Although long-term prognosis appears to be similar for both sexes, there are significant disparities in post-HT morbidity and causes of mortality (noting a higher incidence of rejection in women and of malignancy and cardiac allograft vasculopathy in men). Additional research is required to gain a better understanding of the reasons behind gender disparities in eligibility and outcomes following HT. This would enable the fair allocation of resources and enhance patient care.

Palliative Care Across the Spectrum of Heart Failure

Persons with heart failure (HF) often suffer from poor symptom control, decreased quality of life, and poor communication with their health care providers. These needs are particularly acute in advanced HF, a leading cause of death in the United States. Palliative care, when offered alongside HF disease management, offers improved symptom control, quality of life, communication, and caregiver satisfaction as well as reduced caregiver anxiety. The dynamic nature of the clinical trajectory of HF presents distinct symptom patterns, changing functional status, and uncertainty, which requires an adaptive, dynamic model of palliative care delivery. Due to a limited specialty-trained palliative care workforce, patients and their caregivers often cannot access these benefits, especially in the community. To meet these needs, new models are required that are better informed by high-quality data, engage a range of health care providers in primary palliative care principles, and have clear triggers for specialty palliative care engagement, with specific palliative interventions tailored to patient's illness trajectory and changing needs.

Disparities by Sex, Race, and Ethnicity in Use of Left Ventricular Assist Devices and Heart Transplants Among Patients With Heart Failure With Reduced Ejection Fraction

BACKGROUND

The extent to which sex, racial, and ethnic groups receive advanced heart therapies equitably is unclear. We estimated the population rate of left ventricular assist device (LVAD) and heart transplant (HT) use among (non-Hispanic) White, Hispanic, and (non-Hispanic) Black men and women who have heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

We used a retrospective cohort design combining counts of LVAD and HT procedures from 19 state inpatient discharge databases from 2010 to 2018 with counts of adults with HFrEF. Our primary outcome measures were the number of LVAD and HT procedures per 1000 adults with HFrEF. The main exposures were sex, race, ethnicity, and age. We used Poisson regression models to estimate procedure rates adjusted for differences in age, sex, race, and ethnicity. In 2018, the estimated population of adults aged 35 to 84 years with HFrEF was 69 736, of whom 44% were women. Among men, the LVAD rate was 45.6, and the HT rate was 26.9. Relative to men, LVAD and HT rates were 72% and 62% lower among women (P<0.001). Relative to White men, LVAD and HT rates were 25% and 46% lower (P<0.001) among Black men. Among Hispanic men and women and Black women, LVAD and HT rates were similar (P>0.05) or higher (P<0.01) than among their White counterparts.

CONCLUSIONS

Among adults with HFrEF, the use of LVAD and HT is lower among women and Black men. Health systems and policymakers should identify and ameliorate sources of sex and racial inequities.

Resting respiratory sinus arrythmia and cognitive reappraisal moderate the link between political climate stress and anxiety symptoms in Latina and Black mothers

Guided by the Family Stress Model for minority families, the present study examined the potential buffering effect of resting respiratory sinus arrythmia (RRSA), cognitive reappraisal, and mindfulness on the association between political climate stress (PCS) and anxiety symptoms in a sample of Latina and Black mothers. Participants were 100 mothers living in the southeastern United States. Mothers reported on PCS, cognitive reappraisal, mindfulness, and symptoms of anxiety. RRSA were measured during a resting task. Moderation analyses tested the influence of these three factors (RRSA, cognitive reappraisal, mindfulness) on the relation between PCS and anxiety. Results showed that the relation between PCS and anxiety symptoms was strongest at low levels of RRSA and cognitive reappraisal. At high levels of these two factors, there was no association between PCS and anxiety symptoms. Mothers with high levels of RRSA and cognitive reappraisal may be able to interact with and evaluate environmental stimuli in such a way that allows for adaptive adjustment, buffering against the negative impact of PCS. RRSA and cognitive reappraisal may be important targets of interventions designed to address the rising rates of anxiety symptoms in Latina and Black mothers.

Adverse events after left ventricular assist device implantation linked to psychosocial risk in women and men

BACKGROUND

Reasons for women's increased probability to experience adverse events (AEs) after left ventricular assist device (LVAD) implantation compared with men's remain uncertain. We explored the role of psychosocial risk in the experience of AEs in women and men.

METHODS

INTERMACS patients receiving a primary continuous-flow LVAD between July 2006 and December 2017, median follow-up 13.6 months, were included (n = 20,123, 21.3% women). Time-to-event was calculated with cumulative incidence functions for 10 types of AEs separately (e.g., infection, device malfunction), each time accounting for the competing outcomes death, heart transplant, and device explant due to recovery. Event-specific Cox proportional hazard models were run with a binary psychosocial risk variable (including substance abuse, psychiatric diagnosis, limited social support, limited cognition, repeated noncompliance), controlled for covariates.

RESULTS

Psychosocial risk was more prevalent in men than in women (21.4% vs 17.5%, p < 0.001). Seven out of 10 AEs were more likely in women than in men (e.g., infection 44.5% vs 39.2%, p < 0.001). The association of psychosocial risk with each AE was either stronger in women than in men (e.g., device malfunction HRadj 1.29, 95% confidence interval (CI) (1.06-1.56) vs HRadj 1.10, 95% CI (0.97-1.25); rehospitalization HRadj 1.15, 95% CI (1.02-1.29) vs HRadj 1.03, 95% CI (0.97-1.10) or similar between sexes.

CONCLUSIONS

Independent of clinical parameters, the presence of psychosocial risk is associated with increases in AEs. This suggests that early modification of psychosocial risk factors may have the potential to lower the risk for AEs in this patient population.

Understanding and Investigating Sex-Based Differences in Heart Transplantation: A Call to Action

Women represent only about 25% of heart transplant recipients annually. Although the number of women living with advanced heart failure remains unknown, epidemiologic research suggests that more women should be receiving advanced heart failure therapies. Sex differences in risk factors, presentation, response to pharmacotherapy, and outcomes in heart failure have been well described. Yet, less is known about sex differences in heart transplant candidate selection, waitlist management, donor selection, perioperative considerations, and post-transplant management and outcomes. The purpose of this review was to summarize the existing published reports related to sex differences in heart transplantation, highlighting areas in which sex-based considerations are well described and supported by available evidence, and emphasizing topics that require further study.

Disparities in Adult Patient Selection for Extracorporeal Membrane Oxygenation in the United States: A Population-Level Study

Rationale: Disparities in patient selection for advanced therapeutics in health care have been identified in multiple studies, but it is unclear if disparities exist in patient selection for extracorporeal membrane oxygenation (ECMO), a rapidly expanding critical care resource. Objectives: To determine if disparities exist in patient selection for ECMO based on sex, primary insurance, and median income of the patient's neighborhood. Methods: In a retrospective cohort study using the Nationwide Readmissions Database 2016-2019, we identified patients treated with mechanical ventilation (MV) and/or ECMO with billing codes. Patient sex, insurance, and income level for patients receiving ECMO were compared with the patients treated with MV only, and hierarchical logistic regression with the hospital as a random intercept was used to determine odds of receiving ECMO based on patient demographics. Results: We identified 2,170,752 MV hospitalizations with 18,725 cases of ECMO. Among patients treated with ECMO, 36.1% were female compared with 44.5% of patients treated with> MV only (adjusted odds ratio [aOR] for ECMO, 0.73; 95% confidence interval [CI], 0.70-0.75). Of patients treated with ECMO, 38.1% had private insurance compared with 17.4% of patients treated with MV only. Patients with Medicaid were less likely to receive ECMO than patients with private insurance (aOR, 0.55; 95% CI, 0.52-0.57). Patients treated with ECMO were more likely to live in the highest-income neighborhoods compared with patients treated with MV only (25.1% vs. 17.3%). Patients living in the lowest-income neighborhoods were less likely to receive ECMO than those living in the highest-income neighborhoods (aOR, 0.63; 95% CI, 0.60-0.67). Conclusions: Significant disparities exist in patient selection for ECMO. Female patients, patients with Medicaid, and patients living in the lowest-income neighborhoods are less likely to be treated with ECMO. Despite possible unmeasured confounding, these findings were robust to multiple sensitivity analyses. On the basis of previous work describing disparities in other areas of health care, we speculate that limited access in some neighborhoods, restrictive/biased interhospital transfer practices, differences in patient preferences, and implicit provider bias may contribute to the observed differences. Future studies with more granular data are needed to identify and modify drivers of observed disparities.

Maternal negative affect moderates behavioral and physiological synchrony in Latinx and Black mother-child dyads

Positive behavioral synchrony (PBS) between mothers and children involves the bidirectional exchange of verbal and nonverbal communication. Respiratory sinus arrhythmia (RSA) synchrony reflects the concordance between mother-child physiological states. Both PBS and RSA synchrony can be undermined by psychopathology symptoms. Latinx and Black families may experience contextual stressors that contribute to heightened symptoms of psychopathology, yet minimal research has examined relations between psychopathology symptoms with PBS and RSA synchrony in these families. The present study assessed associations between maternal depressive and child internalizing symptoms, mother and child negative affect (NA), and PBS and RSA synchrony in a sample of 100 Latina and Black mothers (M_age  = 34.48 years, SD = 6.39 years) and their children (M_age  = 6.83 years, SD = 1.50 years). Dyads engaged in a video-recorded stress task where RSA was collected continuously. Videos were later coded for PBS and mother and child NA. Mothers reported on their depressive and child's internalizing symptoms. Maternal NA was associated with weak PBS and negative RSA synchrony. Neither depressive and internalizing symptoms nor child NA were associated with PBS or RSA synchrony. Results highlight the potency of maternal NA on behavioral and physiological synchrony in Latinx and Black families.

Racial and ethnic disparities in psychosocial evaluation and liver transplant waitlisting

Health disparities have been well-described in all stages of the liver transplantation (LT) process. Using data from psychosocial evaluations and the Stanford Integrated Psychosocial Assessment, our objective was to investigate potential racial and ethnic inequities in overall LT waitlisting and not waitlisting for medical or psychosocial reasons. In a cohort of 2271 candidates evaluated for LT from 2014 to 2021 and with 1-8 years of follow-up, no significant associations were noted between race/ethnicity and overall waitlisting and not waitlisting for medical reasons. However, compared with White race, Black race (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.07-2.56) and Hispanic/Latinx ethnicity (OR, 2.10; 95% CI, 1.16-3.78) were associated with not waitlisting for psychosocial reasons. After adjusting for sociodemographic variables, the relationship persisted in both populations: Black (OR, 1.95; 95% CI, 1.12-3.38) and Hispanic/Latinx (OR, 2.29; 95% CI, 1.08-4.86) (reference group, White). High-risk Stanford Integrated Psychosocial Assessment scores were more prevalent in Black and Hispanic/Latinx patients, likely reflecting upstream factors and structural racism. Health systems and LT centers should design programs to combat these disparities and improve equity in access to LT.

Social support and transplantation

PURPOSE OF REVIEW

Social support has many benefits for patients undergoing organ transplantation, though inclusion of it as criteria for transplant listing has been debated. This review highlights recent developments in the research regarding social support and organ transplantation, including the impact of social support on transplantation and caregivers, interventions, COVID-19, and ethical perspectives.

RECENT FINDINGS

Social support and perceived social support have benefits for transplant patients, including increased quality of life and adherence. The providers of social support may also be impacted and the impact may vary based on patient and caregiver characteristics, including organ group and caregiver ethnicity. Debates regarding COVID-19 vaccine requirements for caregivers and ethical concerns about the inclusion of social support as criteria for transplant listing are also explored.

SUMMARY

Transplant patients benefit from social support, though additional research is needed on the impact of social support on transplant outcomes and the utility of the use of social support as criteria for transplant listing. There is also a need for more robust research on diverse caregiver populations, including the identification and use of supportive interventions for caregivers.