1
|
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 2024; 12:1459-1469. [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] [MESH Headings] [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.
Collapse
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.
| |
Collapse
|
2
|
Nair N, Mahesh B, Du D. The Long-Term Survival of LVAD Patients-A TriNetX Database Analysis. J Clin Med 2024; 13:4096. [PMID: 39064136 PMCID: PMC11278369 DOI: 10.3390/jcm13144096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Donor shortage limits the utilization of heart transplantation, making it available for only a fraction of the patients on the transplant waiting list. Therefore, continuous-flow left ventricular assist devices (CF-LVADs) have evolved as a standard of care for end-stage heart failure. It is imperative therefore to investigate long-term survival in this population. Methods: This study assesses the impact of demographics, infections, comorbidities, types of cardiomyopathies, arrhythmias, and end-organ dysfunction on the long-term survival of LVAD recipients. The TriNetX database comprises de-identified patient information across healthcare organizations. The log-rank test assessed post-implant survival effects, while Cox regression was used in the univariate analysis to obtain the Hazard Ratio (HR). All analyses were conducted using the Python programming language and the lifelines library. Results: This study identified CMV, hepatitis A exposure, atrial fibrillation, paroxysmal ventricular tachycardia, ischemic cardiomyopathy, renal dysfunction, diabetes, COPD, mitral valve disease, and essential hypertension as risk factors that impact long-term survival. Interestingly, hypokalemia seems to have a protective effect and gender does not affect survival significantly. Conclusions: This is the first report of a detailed long-term survival assessment of the LVAD population using a decoded database.
Collapse
Affiliation(s)
- Nandini Nair
- Department of Medicine, Division of Cardiology, Penn State Health/PSUCOM, 500 University Drive, Hershey, PA 17033, USA
| | - Balakrishnan Mahesh
- Department of Surgery, Division of Cardiothoracic Surgery, Penn State Health/PSUCOM, 500 University Drive, Hershey, PA 17033, USA;
| | - Dongping Du
- Department of Industrial, Manufacturing and Systems Engineering, Texas Tech University (TTU), Lubbock, TX 79409, USA;
| |
Collapse
|
3
|
Lamba HK, Kherallah R, Nair AP, Shafii AE, Loor G, Kassi M, Chatterjee S, Rogers JG, Civitello AB, Liao KK. Sex Disparities in Left Ventricular Assist Device Implantation: Delayed Presentation and Worse Right Heart Failure. ASAIO J 2024; 70:469-476. [PMID: 38181411 DOI: 10.1097/mat.0000000000002134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024] Open
Abstract
We explored whether women undergo continuous-flow left ventricular assist device (CF-LVAD) implantation in later stages of heart failure (HF) than men, evidenced by worse preoperative right HF (RHF). We also compared two propensity models with and without preoperative RHF to assess its effect on outcomes. INTERMACS was queried from July 2008 to December 2017. Propensity model 1 matched men and women on age ≥50 years, HF etiology, body surface area, INTERMACS class, comorbidities, device strategy, temporary mechanical circulatory support, and device type. Model 2 included these variables plus LV end-diastolic diameter, right atrial pressure/pulmonary capillary wedge pressure, pulmonary artery pulsatility index, and right ventricular ejection fraction. The primary outcome was all-cause mortality. Secondary outcomes comprise RHF, rehospitalization, renal dysfunction, stroke, and device malfunction. In model 1, characteristics were comparable between 3,195 women and 3,195 men, except women more often had preoperative RHF and postoperative right VAD support and had worse 1 year and overall survival. In model 2, after propensity matching for additional risk factors for preoperative RHF, 1,119 women and 1,119 men had comparable post-LVAD implant RVAD use and survival. These findings suggest that women present more often with biventricular failure and after implantation have higher RHF and mortality rates.
Collapse
Affiliation(s)
- Harveen K Lamba
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Riyad Kherallah
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ajith P Nair
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Alexis E Shafii
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Gabriel Loor
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | | | - Subhasis Chatterjee
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| | - Joseph G Rogers
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Andrew B Civitello
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
| | - Kenneth K Liao
- From the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
| |
Collapse
|
4
|
Chehade M, Murali KP, Dickson VV, McCarthy MM. Intersection of social determinants of health with ventricular assist device therapy: An integrative review. Heart Lung 2024; 66:56-70. [PMID: 38583277 DOI: 10.1016/j.hrtlng.2024.04.002] [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: 02/10/2024] [Revised: 03/15/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Social determinants of health (SDOH) may influence the clinical management of patients with heart failure. Further research is warranted on the relationship between SDOH and Ventricular Assist Device (VAD) therapy for heart failure. OBJECTIVES The purpose of this integrative review was to synthesize the state of knowledge on the intersection of SDOH with VAD therapy. METHODS Guided by Whittemore and Knafl's methodology, this literature search captured three concepts of interest including VAD therapy, SDOH, and their domains of intersection with patient selection, decision-making, treatment outcome, and resource allocation. CINAHL, Embase, PsycINFO, PubMed, and Web of Science were searched in March 2023. Articles were included if they were peer-reviewed publications in English, published between 2006 and 2023, conducted in the United States, and examined VAD therapy in the context of adult patients (age ≥ 18 years). RESULTS 22 quantitative studies meeting the inclusion criteria informed the conceptualization of SDOH using the Healthy People 2030 framework. Four themes captured how the identified SDOH intersected with different processes relating to VAD therapy: patient decision-making, healthcare access and resource allocation, patient selection, and treatment outcomes. Most studies addressed the intersection of SDOH with healthcare access and treatment outcomes. CONCLUSION This review highlights substantial gaps in understanding how SDOH intersect with patient and patient selection for VAD. More research using mixed methods designs is warranted. On an institutional level, addressing bias and discrimination may have mitigated health disparities with treatment outcomes, but further research is needed for implementing system-wide change. Standardized assessment of SDOH is recommended throughout clinical practice from patient selection to outpatient VAD care.
Collapse
Affiliation(s)
- Mireille Chehade
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States.
| | - Komal Patel Murali
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| | - Victoria Vaughan Dickson
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| | - Margaret M McCarthy
- Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10010, United States
| |
Collapse
|
5
|
Zhang L, Li Y, Fan CD, Jiang YH, Sheng LS, Song XY, Lin YX, Xue YT, Sun R. Chinese medicinal formula Fu Xin decoction against chronic heart failure by inhibiting the NLRP3/caspase-1/GSDMD pyroptotic pathway. Biomed Pharmacother 2024; 174:116548. [PMID: 38599064 DOI: 10.1016/j.biopha.2024.116548] [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: 12/17/2023] [Revised: 03/28/2024] [Accepted: 04/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Various heart diseases ultimately lead to chronic heart failure (CHF). In CHF, the inflammatory response is associated with pyroptosis, which is mediated by the NOD-like receptor protein 3 (NLRP3) inflammasome. Fu Xin decoction (FXD) is commonly used in clinical practice to treat CHF and improve inflammatory conditions. However, the specific pharmacological mechanisms of action for FXD in these processes have yet to be fully understood. PURPOSE The objective of this study was to examine the protective mechanism of FXT against CHF, both in H9c2 cells and mice. METHOD A CHF mouse model was established, and the effect of FXD was observed via gavage. Cardiac function was evaluated using echocardiography, while serum BNP and LDH levels were analyzed to assess the severity of CHF. Hematoxylin and eosin staining (H&E) and Masson staining were performed to evaluate myocardial pathological changes, and TdT-mediated dUTP Nick-End Labeling staining was used to detect DNA damage. Additionally, doxorubicin was utilized to induce myocardial cell injury in H9c2 cells, establishing a relevant model. CCK8 was used to observe cell viability and detect LDH levels in the cell supernatant. Subsequently, the expression of pyroptosis-related proteins was detected using immunohistochemistry, immunofluorescence, and western blotting. Finally, the pharmacological mechanism of FXD against CHF was further validated by treating H9c2 cells with an NLRP3 activator and inducing NLRP3 overexpression. RESULT According to current research findings, echocardiography demonstrated a significant improvement of cardiac function by FXD, accompanied by reduced levels of BNP and LDH, indicating the amelioration of cardiac injury in CHF mice. FXD exhibited the ability to diminish serum CRP and MCP inflammatory markers in CHF mice. The results of HE and Masson staining analyses revealed a significant reduction in pathological damage of the heart tissue following FXD treatment. The CCK8 assay demonstrated the ability of FXD to enhance H9c2 cell viability, improve cell morphology, decrease LDH levels in the cell supernatant, and alleviate cell damage. Immunohistochemistry, Western blotting, and immunofluorescence staining substantiated the inhibitory effect of FXD on the NLRP3/caspase-1/GSDMD pyroptosis signaling pathway in both CHF and H9c2 cell injury models. Ultimately, the administration of the NLRP3 activator (Nigericin) and the overexpression of NLRP3 counteract the effects of FXD on cardiac protection and pyroptosis inhibition in vitro. CONCLUSION FXD exhibits a cardioprotective effect, improving CHF and alleviating pyroptosis by inhibiting the NLRP3/caspase-1/GSDMD pathway.
Collapse
Affiliation(s)
- Lei Zhang
- The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Yan Li
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Cun-Dong Fan
- Department of Neurology, Key Lab of Cerebral Microcirculation in Universities of Shandong, Shandong First Medical University & Shandong Academy of Medical Sciences, Taian, Shandong, China
| | - Yong-Hao Jiang
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Li-Song Sheng
- Advanced Medical Research Institute, Shandong University, Jinan, Shandong, China; Shandong Academy of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Xu-Yu Song
- The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Yu-Xing Lin
- The Second Hospital of Shandong University, Jinan, Shandong, China
| | - Yi-Tao Xue
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China.
| | - Rong Sun
- The Second Hospital of Shandong University, Jinan, Shandong, China; Advanced Medical Research Institute, Shandong University, Jinan, Shandong, China.
| |
Collapse
|
6
|
Tisdale R, Der-Martirosian C, Yoo C, Chu K, Zulman D, Leung L. Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease. J Gen Intern Med 2024; 39:60-67. [PMID: 38252244 PMCID: PMC10937859 DOI: 10.1007/s11606-023-08475-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/11/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered. OBJECTIVE Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension. DESIGN Retrospective cohort study. PATIENTS Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years. MAIN MEASURES The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering. KEY RESULTS Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06). CONCLUSIONS Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.
Collapse
Affiliation(s)
- Rebecca Tisdale
- Veterans Affairs Palo Alto Healthcare System/Center for Innovation to Implementation (Ci2i), Palo Alto, CA, USA.
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA.
| | - Claudia Der-Martirosian
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
| | - Caroline Yoo
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
| | - Karen Chu
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
- Veterans Emergency Management Evaluation Center (VEMEC), North Hills, CA, USA
| | - Donna Zulman
- Veterans Affairs Palo Alto Healthcare System/Center for Innovation to Implementation (Ci2i), Palo Alto, CA, USA
- Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Lucinda Leung
- Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA, USA
- Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| |
Collapse
|
7
|
Rose SW, Strackman BW, Gilbert ON, Lasser KE, Paasche‐Orlow MK, Lin M, Saylor G, Hanchate AD. 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. J Am Heart Assoc 2024; 13:e031021. [PMID: 38166429 PMCID: PMC10926796 DOI: 10.1161/jaha.123.031021] [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: 07/04/2023] [Accepted: 10/11/2023] [Indexed: 01/04/2024]
Abstract
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.
Collapse
Affiliation(s)
- Scott W. Rose
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Braden W. Strackman
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Olivia N. Gilbert
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Karen E. Lasser
- Section of General Internal MedicineBoston University School of MedicineBostonMAUSA
| | | | - Meng‐Yun Lin
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Georgia Saylor
- Section of Cardiology Medicine, Department of MedicineWake Forest University School of MedicineWinston‐SalemNCUSA
| | - Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNCUSA
- Section of General Internal MedicineBoston University School of MedicineBostonMAUSA
| |
Collapse
|
8
|
Jawaid O, Salerno C, Ravichandran A. Left Ventricular Assist Device and the Current State of the Art: HeartMate 3 at 5 Years. Heart Fail Clin 2024; 20:83-89. [PMID: 37953024 DOI: 10.1016/j.hfc.2023.05.005] [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] [Indexed: 11/14/2023]
Abstract
Left ventricular assist devices (LVADs) or cardiac transplantation are the two prevailing methods of treating patients with end-stage heart failure. The availability of donor hearts is insufficient to meet the needs of patients with advanced heart failure. LVADs offer a potential alternative to transplantation for those patients who cannot wait or are otherwise unsuited for cardiac transplantation. The field has made tremendous progress in the past 20 years. In this review, the current state of the art is summarized with respect to current generation LVADs.
Collapse
Affiliation(s)
- Omar Jawaid
- St. Vincents' Ascension, 8333 Naab Road, Indianapolis, IN 46260, USA
| | - Christopher Salerno
- University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | | |
Collapse
|
9
|
Ahmed MM, Meece LE, Guo Y, Jeng EI, Parker AM, Vilaro JR, Al-Ani MA, Aranda JM. Left Ventricular Assist Device Use in Minorities: An Analysis of the National Inpatient Sample. ASAIO J 2024; 70:14-21. [PMID: 37788482 DOI: 10.1097/mat.0000000000002046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Minorities are less likely to receive a left ventricular assist device (LVAD). This, however, is based on total implant data. By examining rates of LVAD implant among patients admitted with heart failure complicated by cardiogenic shock, we sought to further elucidate LVAD utilization rates and racial disparities. Utilizing the National Inpatient Sample from 2013 to 2019, all patients admitted with a primary diagnosis of heart failure complicated by cardiogenic shock were included for analysis. Those who then received an LVAD during that hospitalization defined the LVAD utilization which was examined for any racial disparities. Left ventricular assist device utilization was low across all racial groups with no significant difference noted in univariate analysis. Non-Hispanic Blacks had the highest length of stay (LOS), the highest proportion of discharge to home (71.52%), and the lowest inpatient mortality (6.33%). Multivariable modeling confirmed the relationship between race and LOS; however, no differences were noted in mortality. Non-Hispanic Blacks were found to be less likely to receive an LVAD; however, when controlling for payer, median household income, and comorbidities, this relationship was no longer seen. Left ventricular assist devices remain an underutilized therapy in cardiogenic shock. When using a multivariable model, race does not appear to affect LVAD utilization.
Collapse
Affiliation(s)
- Mustafa M Ahmed
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Lauren E Meece
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida
| | - Eric I Jeng
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Alex M Parker
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan R Vilaro
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Mohammad A Al-Ani
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan M Aranda
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| |
Collapse
|
10
|
Subramaniam A, van Houten H, Redfield MM, Sangaralingham LR, Savitz ST, Glasgow A, Schulte PJ, LeMond LM, Dunlay SM. Advanced Heart Failure Characteristics and Outcomes in Commercially Insured U.S. Adults. JACC. HEART FAILURE 2023; 11:1595-1606. [PMID: 37589611 PMCID: PMC10752371 DOI: 10.1016/j.jchf.2023.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 06/13/2023] [Accepted: 06/28/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The characteristics and outcomes of patients with advanced heart failure (HF) have been poorly defined due to challenges in applying the complex advanced HF definition broadly to populations. OBJECTIVES In this study, the authors sought to apply a validated advanced HF algorithm to a large U.S. administrative claims database and describe the population and use of advanced HF therapies. METHODS This study included adults with advanced HF identified in the OptumLabs Data Warehouse from 2009 to 2019. The algorithm for advanced HF required 2 hospitalizations for HF plus 1 additional sign of advanced HF in a 12-month period. The association of baseline characteristics with mortality was examined with the use of Cox proportional hazards models. Associations of patient characteristics with advanced therapies were estimated with the use of cause-specific Cox proportional hazard models. RESULTS In 60,197 patients identified with advanced HF, the mean age was 73 years, 51.5% were men, and 64.3% were non-Hispanic White, 1.9% Asian, 21.2% Black, and 8.2% Hispanic. The median survival with advanced HF was 2.0 years (IQR: 0.4-5.5 years). Differences in mortality and use of advanced therapies by age, sex, and race/ethnicity were observed. Adjusted mortality was higher in patients who were older, male, non-Hispanic White, and from rural areas (P < 0.05 for all). Advanced therapies were used less in older patients and women (P < 0.05 for both). Black patients were more likely to be treated with a left ventricular assist device (P = 0.010) but less likely to receive a heart transplant compared with White patients (P = 0.034). CONCLUSIONS In U.S. adults with advanced HF, variation in outcomes and use of advanced therapies exist by age, sex, and race/ethnicity.
Collapse
Affiliation(s)
- Anna Subramaniam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Holly van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA; Optum Labs, Eden Prairie, Minnesota
| | - Margaret M Redfield
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel T Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amy Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip J Schulte
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa M LeMond
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
11
|
Dixon DD, Knapp SM, Ilonze O, Lewsey SC, Mazimba S, Mohammed S, Van Spall HGC, Breathett K. Racial and Ethnic Disparities in Ambulatory Heart Failure Ventricular Assist Device Implantation and Survival. JACC. HEART FAILURE 2023; 11:1397-1407. [PMID: 37389504 PMCID: PMC10614028 DOI: 10.1016/j.jchf.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Durable left ventricular assist devices (VADs) improve survival in eligible patients, but allocation has been associated with patient race in addition to presumed heart failure (HF) severity. OBJECTIVES This study sought to determine racial and ethnic differences in VAD implantation rates and post-VAD survival among patients with ambulatory HF. METHODS Using the INTERMACS (Interagency Registry of Mechanically Assisted Circulatory Support) database (2012-2017), this study examined census-adjusted VAD implantation rates by race, ethnicity, and sex in patients with ambulatory HF (INTERMACS profile 4-7) using negative binomial models with quadratic effect of time. Survival was evaluated using Kaplan-Meier estimates and Cox models adjusted for clinically relevant variables and an interaction of time with race/ethnicity. RESULTS VADs were implanted in 2,256 adult patients with ambulatory HF (78.3% White, 16.4% Black, and 5.3% Hispanic). The median age at implantation was lowest in Black patients. Implantation rates peaked between 2013 and 2015 before declining in all demographic groups. From 2012 to 2017, implantation rates overlapped for Black and White patients but were lower for Hispanic patients. Post-VAD survival was significantly different among the 3 groups (log rank P = 0.0067), with higher estimated survival among Black vs White patients (12-month survival: Black patients: 90% [95% CI: 86%-93%]; White patients: 82% [95% CI: 80%-84%]). Low sample size for Hispanic patients resulted in imprecise survival estimates (12-month survival: 85% [95% CI: 76%-90%]). CONCLUSIONS Black and White patients with ambulatory HF had similar VAD implantation rates but rates were lower for Hispanic patients. Survival differed among the 3 groups, with the highest estimated survival at 12 months in Black patients. Given higher HF burden in minoritized populations, further investigation is needed to understand differences in VAD implantation rates in Black and Hispanic patients.
Collapse
Affiliation(s)
- Debra D Dixon
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shannon M Knapp
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Onyedika Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sabra C Lewsey
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Selma Mohammed
- Division of Cardiovascular Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Harriette G C Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, McMaster University School of Medicine, Hamilton, Ontario, Canada
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| |
Collapse
|
12
|
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.
Collapse
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.
| |
Collapse
|
13
|
Hofmeyer M, Haas GJ, Jordan E, Cao J, Kransdorf E, Ewald GA, Morris AA, Owens A, Lowes B, Stoller D, Tang WHW, Garg S, Trachtenberg BH, Shah P, Pamboukian SV, Sweitzer NK, Wheeler MT, Wilcox JE, Katz S, Pan S, Jimenez J, Smart F, Wang J, Gottlieb SS, Judge DP, Moore CK, Huggins GS, Kinnamon DD, Ni H, Hershberger RE. Rare Variant Genetics and Dilated Cardiomyopathy Severity: The DCM Precision Medicine Study. Circulation 2023; 148:872-881. [PMID: 37641966 PMCID: PMC10530109 DOI: 10.1161/circulationaha.123.064847] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/14/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) can lead to advanced disease, defined herein as necessitating a durable left ventricular assist device or a heart transplant (LVAD/HT). DCM is known to have a genetic basis, but the association of rare variant genetics with advanced DCM has not been studied. METHODS We analyzed clinical and genetic sequence data from patients enrolled between 2016 and 2021 in the US multisite DCM Precision Medicine Study, which was a geographically diverse, multiracial, multiethnic cohort. Clinical evaluation included standardized patient interview and medical record query forms. DCM severity was classified into 3 groups: patients with advanced disease with LVAD/HT; patients with an implantable cardioverter defibrillator (ICD) only; or patients with no ICD or LVAD/HT. Rare variants in 36 DCM genes were classified as pathogenic or likely pathogenic or variants of uncertain significance. Confounding factors we considered included demographic characteristics, lifestyle factors, access to care, DCM duration, and comorbidities. Crude and adjusted associations between DCM severity and rare variant genetic findings were assessed using multinomial models with generalized logit link. RESULTS Patients' mean (SD) age was 51.9 (13.6) years; 42% were of African ancestry, 56% were of European ancestry, and 44% were female. Of 1198 patients, 347 had LVAD/HT, 511 had an ICD, and 340 had no LVAD/HT or ICD. The percentage of patients with pathogenic or likely pathogenic variants was 26.2%, 15.9%, and 15.0% for those with LVAD/HT, ICD only, or neither, respectively. After controlling for sociodemographic characteristics and comorbidities, patients with DCM with LVAD/HT were more likely than those without LVAD/HT or ICD to have DCM-related pathogenic or likely pathogenic rare variants (odds ratio, 2.3 [95% CI, 1.5-3.6]). The association did not differ by ancestry. Rare variant genetic findings were similar between patients with DCM with an ICD and those without LVAD/HT or ICD. CONCLUSIONS Advanced DCM was associated with higher odds of rare variants in DCM genes adjudicated as pathogenic or likely pathogenic, compared with individuals with less severe DCM. This finding may help assess the risk of outcomes in management of patients with DCM and their at-risk family members. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03037632.
Collapse
Affiliation(s)
- Mark Hofmeyer
- MedStar Health Research Institute, Medstar Washington Hospital Center, Washington, DC
| | - Garrie J. Haas
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Elizabeth Jordan
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jinwen Cao
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha, NE
| | | | - W. H. Wilson Tang
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sonia Garg
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Barry H. Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, J.C. Walter Jr. Transplant Center, Houston TX
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, VA
| | - Salpy V. Pamboukian
- University of Alabama, Birmingham, AL during study conduct, current affiliation, University of Washington, Seattle, WA
| | - Nancy K. Sweitzer
- Sarver Heart Center, University of Arizona, Tucson, AZ during study conduct, current affiliation, Washington University, St. Louis, MO
| | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jane E. Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stuart Katz
- New York University Langone Medical Center, New York, NY
| | - Stephen Pan
- New York University Langone Medical Center, New York, NY
- current affiliation, Department of Cardiology, Westchester Medical Center & New York Medical College, Valhalla, NY
| | - Javier Jimenez
- Miami Cardiac & Vascular Institute, Baptist Health South, Miami, FL
| | - Frank Smart
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | | | | | - Gordon S. Huggins
- Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Daniel D. Kinnamon
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Hanyu Ni
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Ray E. Hershberger
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | | |
Collapse
|
14
|
Breathett K, Yee R, Pool N, Thomas Hebdon MC, Knapp SM, Herrera-Theut K, de Groot E, Yee E, Allen LA, Hasan A, Lindenfeld J, Calhoun E, Carnes M, Sweitzer NK. Group Dynamics and Allocation of Advanced Heart Failure Therapies-Heart Transplants and Ventricular Assist Devices-By Gender, Racial, and Ethnic Group. J Am Heart Assoc 2023; 12:e027701. [PMID: 36846988 PMCID: PMC10111441 DOI: 10.1161/jaha.122.027701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Background US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. Methods and Results We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. Conclusions Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation.
Collapse
Affiliation(s)
| | - Ryan Yee
- Division of Cardiovascular Medicine, Research Team Indiana University Indianapolis IN
| | - Natalie Pool
- School of Nursing University of Northern Colorado Greeley CO
| | | | - Shannon M Knapp
- Division of Cardiovascular Medicine Indiana University Indianapolis IN
| | | | - Esther de Groot
- Department of General Practice University Medical Center Utrecht Utrecht Netherlands
| | - Erika Yee
- School of Medicine University of Arizona Tucson AZ
| | - Larry A Allen
- Division of Cardiovascular Medicine University of Colorado Denver CO
| | - Ayesha Hasan
- Division of Cardiovascular Medicine The Ohio State University Columbus OH
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine Vanderbilt University Nashville TN
| | | | - Molly Carnes
- Department of Medicine University of Wisconsin Madison WI
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine University of Washington at St Louis St Louis MO
| |
Collapse
|
15
|
Trends in Contemporary Use of Ventricular Assist Devices in Children Awaiting Heart Transplantation and Their Outcomes by Race/Ethnicity. ASAIO J 2023; 69:210-217. [PMID: 35438653 DOI: 10.1097/mat.0000000000001747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
This retrospective study included children aged ≤18 years who had durable ventricular assist devices (VADs) as a bridge to transplantation from the United Network Organ Sharing (UNOS) database between 2011 and 2020. We evaluated 90 day waitlist mortality and 1 year posttransplant mortality after VAD implantation in children stratified by race/ethnicity: Black, White, and Others. The VAD was used in a higher proportion of Black children listed for heart transplantation (HT) (26%) versus Other (25%) versus White (22%); p < 0.01. Black children had Medicaid health insurance coverage (67%) predominantly at the time of listing for HT. There was no significant overall difference in waitlist survival among the three groups supported with VAD at the time of listing (log-rank p = 0.4). On the other hand, the 90 day waitlist mortality after the VAD implantation at listing and while listed was the lowest among Black (6%) compared with White (13%) and Other (14%) ( p < 0.01). The multivariate regression analysis showed that Other race (hazard ratio [HR], 2.29; p < 0.01), Black race (HR, 2.13; p < 0.01), use of mechanical ventilation (HR, 1.72; p = 0.01), and Medicaid insurance (HR, 1.54; p = 0.04) were independently associated with increased 1 year posttransplant mortality. In conclusion, Black children had more access to durable VAD support than White children. The 90 day waitlist mortality was significantly lower in Black children compared with White and Other after VAD implantation. However, Black and Other racial/ethnic children with VAD at transplant had higher 1 year posttransplant mortality than White children. Future studies to elucidate the reasons for these disparities are needed.
Collapse
|
16
|
Cascino TM, Colvin M, Lanfear DE, Richards B, Khalatbari S, Mann DL, Taddei-Peters WC, Jeffries N, Watkins DC, Stewart GC, Aaronson KD. Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study. Circ Heart Fail 2023; 16:e009745. [PMID: 36259388 PMCID: PMC9851944 DOI: 10.1161/circheartfailure.122.009745] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/24/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect. METHODS We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies. RESULTS The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities. CONCLUSIONS Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01369407.
Collapse
Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| | | | - Blair Richards
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | - Shokoufeh Khalatbari
- University of Michigan, Michigan Institute for Clinical and Health Research, Ann Arbor, MI
| | | | | | - Neal Jeffries
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, MI
| |
Collapse
|
17
|
Shore S, O'Leary M, Kamdar N, Harrod M, Silveira MJ, Hummel SL, Nallamothu BK. Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia. J Am Heart Assoc 2022; 11:e025730. [PMID: 36382963 PMCID: PMC9851455 DOI: 10.1161/jaha.122.025730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.
Collapse
Affiliation(s)
- Supriya Shore
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Michael O'Leary
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Neil Kamdar
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Molly Harrod
- Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| | - Maria J. Silveira
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Veterans Affairs Geriatric Research Education and Clinical CenterAnn ArborMI
| | - Scott L. Hummel
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI,Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| | - Brahmajee K. Nallamothu
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI,Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| |
Collapse
|
18
|
Mazimba S. Toward equitable utilization of durable left ventricular assist device therapy in advanced heart failure-Raising the veil of health disparities. J Card Surg 2022; 37:3595-3597. [PMID: 36124425 PMCID: PMC9825975 DOI: 10.1111/jocs.16933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/11/2023]
Abstract
Heart failure (HF) is a progressive disease with high attendant morbidity and mortality. Contemporary guideline-directed medical therapies have led to remarkable improvements in HF outcomes. However, in a subset of patients, progression to advanced HF stages requiring durable left ventricular assist device (LVAD) and or heart transplantation is inevitable. LVADs improve survival and quality of life in eligible patients with advanced HF. However, access to LVAD therapy is marked by disparities, attributable to race and ethnicity, social-economic status, geography, and sex and gender categories. This commentary addresses the findings by Jones and colleagues on "The Impact of Race on Utilization of Durable Left Ventricular Assist Device Therapy in Patients with Advanced Heart Failure" and also highlights the importance of social determinants of health in defining health disparities as well as the urgent work needed to improve HF clinical outcomes by dismantling these disparities.
Collapse
Affiliation(s)
- Sula Mazimba
- Department of Medicine, University of VirginiaDivision of Cardiovascular MedicineCharlottesvilleVirginiaUSA
| |
Collapse
|
19
|
Cascino TM, McCullough JS, Wu X, Pienta MJ, Stewart JW, Hawkins RB, Brescia AA, Abou el ala A, Zhang M, Noly PE, Haft JW, Cowger JA, Colvin M, Aaronson KD, Pagani FD, Likosky DS. Comparison of Evaluations for Heart Transplant Before Durable Left Ventricular Assist Device and Subsequent Receipt of Transplant at Transplant vs Nontransplant Centers. JAMA Netw Open 2022; 5:e2240646. [PMID: 36342716 PMCID: PMC9641540 DOI: 10.1001/jamanetworkopen.2022.40646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022] Open
Abstract
Importance In 2020, the Centers for Medicare & Medicaid Services revised its national coverage determination, removing the requirement to obtain review from a Medicare-approved heart transplant center to implant a durable left ventricular assist device (LVAD) for bridge-to-transplant (BTT) intent at an LVAD-only center. The association between center-level transplant availability and access to heart transplant, the gold-standard therapy for advanced heart failure (HF), is unknown. Objective To investigate the association of center transplant availability with LVAD implant strategies and subsequent heart transplant following LVAD implant before the Centers for Medicare & Medicaid Services policy change. Design, Setting, and Participants A retrospective cohort study of the Society of Thoracic Surgeons Intermacs multicenter US registry database was conducted from April 1, 2012, to June 30, 2020. The population included patients with HF receiving a primary durable LVAD. Exposures LVAD center transplant availability (LVAD/transplant vs LVAD only). Main Outcomes and Measures The primary outcomes were implant strategy as BTT and subsequent transplant by 2 years. Covariates that might affect listing strategy and outcomes were included (eg, patient demographic characteristics, comorbidities) in multivariable models. Parameters for BTT listing were estimated using logistic regression with center-level random effects and for receipt of a transplant using a Cox proportional hazards regression model with death as a competing event. Results The sample included 22 221 LVAD recipients with a median age of 59.0 (IQR, 50.0-67.0) years, of whom 17 420 (78.4%) were male and 3156 (14.2%) received implants at LVAD-only centers. Receiving an LVAD at an LVAD/transplant center was associated with a 79% increased adjusted odds of BTT LVAD designation (odds ratio, 1.79; 95% CI, 1.35-2.38; P < .001). The 2-year transplant rate following LVAD implant was 25.6% at LVAD/transplant centers and 11.9% at LVAD-only centers. There was an associated 33% increased rate of transplant at LVAD/transplant centers compared with LVAD-only centers (adjusted hazard ratio, 1.33; 95% CI, 1.17-1.51) with a similar hazard for death at 2 years (adjusted hazard ratio, 0.99; 95% CI, 0.90-1.08). Conclusions and Relevance Receiving an LVAD at an LVAD-transplant center was associated with increased odds of BTT intent at implant and subsequent transplant receipt for patients at 2 years. The findings of this study suggest that Centers for Medicare & Medicaid Services policy change may have the unintended consequence of further increasing inequities in access to transplant among patients at LVAD-only centers.
Collapse
Affiliation(s)
- Thomas M. Cascino
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Xiaoting Wu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Michael J. Pienta
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - James W. Stewart
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | | | - Ashraf Abou el ala
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | | | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Jennifer A. Cowger
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Monica Colvin
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Keith D. Aaronson
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
20
|
Disparities in Practice Patterns by Sex, Race, and Ethnicity in Patients Referred for Advanced Heart Failure Therapies. Am J Cardiol 2022; 185:46-52. [DOI: 10.1016/j.amjcard.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/29/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
|
21
|
Ilonze O, Free K, Breathett K. Unequitable Heart Failure Therapy for Black, Hispanic and American-Indian Patients. Card Fail Rev 2022; 8:e25. [PMID: 35865458 PMCID: PMC9295006 DOI: 10.15420/cfr.2022.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Despite the high prevalence of heart failure among Black and Hispanic populations, patients of colour are frequently under-prescribed guideline-directed medical therapy (GDMT) and American-Indian populations are not well characterised. Clinical inertia, financial toxicity, underrepresentation in trials, non-trustworthy medical systems, bias and structural racism are contributing factors. There is an urgent need to develop evidence-based strategies to increase the uptake of GDMT for heart failure in patients of colour. Postulated strategies include prescribing all GDMT upon first encounter, aggressive outpatient uptitration of GDMT, intervening upon social determinants of health, addressing bias and racism through changing processes or policies that unfairly disadvantage patients of colour, engagement of stakeholders and implementation of national quality improvement programmes.
Collapse
Affiliation(s)
- Onyedika Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis, IN, US
| | - Kendall Free
- Department of Biofunction Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis, IN, US
| |
Collapse
|
22
|
Cascino TM, Somanchi S, Colvin M, Chung GS, Brescia AA, Pienta M, Thompson MP, Stewart JW, Sukul D, Watkins DC, Pagani FD, Likosky DS, Aaronson KD, McCullough JS. Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2223080. [PMID: 35895063 PMCID: PMC9331085 DOI: 10.1001/jamanetworkopen.2022.23080] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/20/2022] [Indexed: 11/14/2022] Open
Abstract
Importance While left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood. Objectives To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatment decisions among patients for whom clinician discretion has a more prominent role. Design, Setting, and Participants This retrospective cohort study of 12 310 Medicare beneficiaries used 100% Medicare Fee-for-Service administrative claims. Included patients had been admitted for heart failure from 2008 to 2014. Data were collected from July 2007 to December 2015 and analyzed from August 23, 2020, to May 15, 2022. Exposures Beneficiary race and sex. Main Outcomes and Measures The propensity for LVAD implantation was based on clinical risk factors from the 6 months preceding HF admission using XGBoost and the synthetic minority oversampling technique. Beneficiaries with a 5% or greater probability of receiving an LVAD were included. Logistic regression models were estimated to measure associations of race and sex with LVAD receipt adjusting for clinical characteristics and social determinants of health (eg, distance from LVAD center, Medicare low-income subsidy, neighborhood deprivation). Next, 1-year mortality after LVAD was examined. Results The analytic sample included 12 310 beneficiaries, of whom 22.9% (n = 2819) were Black and 23.7% (n = 2920) were women. In multivariable models, Black beneficiaries were 3.0% (0.2% to 5.8%) less likely to receive LVAD than White beneficiaries, and women were 7.9% (5.6% to 10.2%) less likely to receive LVAD than men. Individual poverty and worse neighborhood deprivation were associated with reduced use, 2.9% (0.4% to 5.3%) and 6.7% (2.9% to 10.5%), respectively, but these measures did little to explain observed disparities. The racial disparity was concentrated among patients with a low propensity score (propensity score <0.52). One-year survival by race and sex were similar on average, but Black patients with a low propensity score experienced improved survival (7.2% [95% CI, 0.9% to 13.5%]). Conclusions and Relevance In this cohort study of Medicare beneficiaries hospitalized for HF, disparities in LVAD use by race and sex existed and were not explained by clinical characteristics or social determinants of health. The treatment and post-LVAD survival by race were equivalent among the most obvious LVAD candidates. However, there was differential use and outcomes among less clear-cut LVAD candidates, with lower use but improved survival among Black patients. Inequity in LVAD access may have resulted from differences in clinician decision-making because of systemic racism and discrimination, implicit bias, or patient preference.
Collapse
Affiliation(s)
- Thomas M. Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Sriram Somanchi
- University of Notre Dame, Mendoza College of Business, Department of IT Analytics and Operations, Notre Dame, Indiana
| | - Monica Colvin
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Grace S. Chung
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
| | | | - Michael Pienta
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | | | - James W. Stewart
- University of Michigan, Department of Cardiac Surgery, Ann Arbor
| | - Devraj Sukul
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | | | | | | | - Keith D. Aaronson
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor
| | - Jeffrey S. McCullough
- University of Michigan School of Public Health, Department of Health Management and Policy, Ann Arbor
| |
Collapse
|
23
|
Johnson AE, Brewer LC, Echols MR, Mazimba S, Shah RU, Breathett K. Utilizing Artificial Intelligence to Enhance Health Equity Among Patients with Heart Failure. Heart Fail Clin 2022; 18:259-273. [PMID: 35341539 PMCID: PMC8988237 DOI: 10.1016/j.hfc.2021.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patients with heart failure (HF) are heterogeneous with various intrapersonal and interpersonal characteristics contributing to clinical outcomes. Bias, structural racism, and social determinants of health have been implicated in unequal treatment of patients with HF. Through several methodologies, artificial intelligence (AI) can provide models in HF prediction, prognostication, and provision of care, which may help prevent unequal outcomes. This review highlights AI as a strategy to address racial inequalities in HF; discusses key AI definitions within a health equity context; describes the current uses of AI in HF, strengths and harms in using AI; and offers recommendations for future directions.
Collapse
Affiliation(s)
- Amber E Johnson
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Veterans Affairs Pittsburgh Health System, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - LaPrincess C Brewer
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Melvin R Echols
- Division of Cardiovascular Medicine, Morehouse School of Medicine, 720 Westview Drive, Atlanta, GA 30310, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Advanced Heart Failure and Transplant Center, University of Virginia, 2nd Floor, 1221 Lee Street, Charlottesville, VA 22903, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah, 30 N 1900 E, Cardiology, 4A100, Salt Lake City, UT 84132, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245046, Tucson, AZ 85724, USA.
| |
Collapse
|
24
|
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: 1] [Impact Index Per Article: 0.5] [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.
Collapse
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
| |
Collapse
|
25
|
Everitt IK, Trinh KV, Underberg DL, Beach L, Khan SS. Moving the Paradigm Forward for Prediction and Risk-Based Primary Prevention of Heart Failure in Special Populations. Curr Atheroscler Rep 2022; 24:343-356. [PMID: 35235166 DOI: 10.1007/s11883-022-01009-7] [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] [Accepted: 01/17/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Heart failure (HF) treatment paradigms increasingly recognize the importance of primary prevention. This review explores factors that enhance HF risk, summarizes evidence supporting the pharmacologic primary prevention of HF, and notes barriers to the implementation of primary prevention of HF with a focus on female and sexual and gender minority patients. RECENT FINDINGS HF has pathophysiologic sex-specific distinctions, suggesting that sex-specific preventive strategies may be beneficial. Pharmacologic agents that have shown benefit in reducing the risk of HF address the pathobiology underpinning these sex-specific risk factors. The implementation of pharmacologic therapies for primary prevention of HF needs to consider a risk-based model. Current pharmacotherapies hold mechanistic promise for the primary prevention of HF in females and gender and sexual minorities, although research is needed to understand the specific populations most likely to benefit. There are significant systemic barriers to the equitable provision of HF primary prevention.
Collapse
Affiliation(s)
- Ian K Everitt
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine V Trinh
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel L Underberg
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren Beach
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Sadiya S Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA.
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| |
Collapse
|
26
|
Kittleson MM. Biology or Disparity? Untangling Racial Differences in Val122Ile Transthyretin Cardiac Amyloidosis. J Card Fail 2022; 28:960-962. [PMID: 35041934 DOI: 10.1016/j.cardfail.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| |
Collapse
|
27
|
Piña IL, Jimenez S, Lewis EF, Morris AA, Onwuanyi A, Tam E, Ventura HO. Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9. J Am Coll Cardiol 2021; 78:2589-2598. [PMID: 34887145 DOI: 10.1016/j.jacc.2021.06.058] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
Heart failure (HF) affects >6 million Americans, with variations in incidence, prevalence, and clinical outcomes by race/ethnicity. Black adults have the highest risk for HF, with earlier age of onset and the highest risk of death and hospitalizations. The risk of hospitalizations for Hispanic patients is higher than White patients. Data on HF in Asian individuals are more limited. However, the higher burden of traditional cardiovascular risk factors, particularly among South Asian adults, is associated with increased risk of HF. The role of environmental, socioeconomic, and other social determinants of health, more likely for Black and Hispanic patients, are increasingly recognized as independent risk factors for HF and worse outcomes. Structural racism and implicit bias are drivers of health care disparities in the United States. This paper will review the clinical, physiological, and social determinants of HF risk, unique for race/ethnic minorities, and offer solutions to address systems of inequality that need to be recognized and dismantled/eradicated.
Collapse
Affiliation(s)
| | | | | | - Alanna A Morris
- Emory University, Atlanta, Georgia, USA. https://twitter.com/morrismd
| | | | - Edlira Tam
- Montefiore Medical Center, Bronx, New York, USA
| | | |
Collapse
|
28
|
Morris AA, Khazanie P, Drazner MH, Albert NM, Breathett K, Cooper LB, Eisen HJ, O'Gara P, Russell SD. Guidance for Timely and Appropriate Referral of Patients With Advanced Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e238-e250. [PMID: 34503343 DOI: 10.1161/cir.0000000000001016] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Among the estimated 6.2 million Americans living with heart failure (HF), ≈5%/y may progress to advanced, or stage D, disease. Advanced HF has a high morbidity and mortality, such that early recognition of this condition is important to optimize care. Delayed referral or lack of referral in patients who are likely to derive benefit from an advanced HF evaluation can have important adverse consequences for patients and their families. A 2-step process can be used by practitioners when considering referral of a patient with advanced HF for consideration of advanced therapies, focused on recognizing the clinical clues associated with stage D HF and assessing potential benefits of referral to an advanced HF center. Although patients are often referred to an advanced HF center to undergo evaluation for advanced therapies such as heart transplantation or implantation of a left ventricular assist device, there are other reasons to refer, including access to the infrastructure and multidisciplinary team of the advanced HF center that offers a broad range of expertise. The intent of this statement is to provide a framework for practitioners and health systems to help identify and refer patients with HF who are most likely to derive benefit from referral to an advanced HF center.
Collapse
|
29
|
Averbuch T, Mohamed MO, Islam S, Defilippis EM, Breathett K, Alkhouli MA, Michos ED, Martin GP, Kontopantelis E, Mamas MA, Van Spall HGC. The Association Between Socioeconomic Status, Sex, Race / Ethnicity and In-Hospital Mortality Among Patients Hospitalized for Heart Failure. J Card Fail 2021; 28:697-709. [PMID: 34628014 DOI: 10.1016/j.cardfail.2021.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/11/2021] [Accepted: 09/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The association between socioeconomic status (SES), sex, race / ethnicity and outcomes during hospitalization for heart failure (HF) has not previously been investigated. METHODS AND RESULTS We analyzed HF hospitalizations in the United States National Inpatient Sample between 2015 and 2017. Using a hierarchical, multivariable Poisson regression model to adjust for hospital- and patient-level factors, we assessed the association between SES, sex, and race / ethnicity and all-cause in-hospital mortality. We estimated the direct costs (USD) across SES groups. Among 4,287,478 HF hospitalizations, 40.8% were in high SES, 48.7% in female, and 70.0% in White patients. Relative to these comparators, low SES (homelessness or lowest quartile of median neighborhood income) (relative risk [RR] 1.02, 95% confidence interval [CI] 1.00-1.05) and male sex (RR 1.09, 95% CI 1.07-1.11) were associated with increased risk, whereas Black (RR 0.79, 95% CI 0.76-0.81) and Hispanic (RR 0.90, 95% CI 0.86-0.93) race / ethnicity were associated with a decreased risk of in-hospital mortality (5.1% of all hospitalizations). There were significant interactions between race / ethnicity and both, SES (P < .01) and sex (P = .04), such that racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients. The median direct cost of admission was lower in low vs high SES groups ($9324.60 vs $10,940.40), female vs male patients ($9866.60 vs $10,217.10), and Black vs White patients ($9077.20 vs $10,019.80). The median costs increased with SES in all demographic groups primarily related to greater procedural utilization. CONCLUSIONS SES, sex, and race / ethnicity were independently associated with in-hospital mortality during HF hospitalization, highlighting possible care disparities. Racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients.
Collapse
Affiliation(s)
- T Averbuch
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - M O Mohamed
- Department of Cardiology, Keele University, Keele, UK
| | - S Islam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Biostatistics, Population Health Research Institute, Hamilton, Ontario, Canada
| | - E M Defilippis
- Department of Cardiology, Columbia University, New York, New York
| | - K Breathett
- Department of Medicine, University of Arizona, Tucson, Arizona
| | - M A Alkhouli
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, New York
| | - E D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - G P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - E Kontopantelis
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - M A Mamas
- Department of Cardiology, Keele University, Keele, UK
| | - H G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
| |
Collapse
|
30
|
Sheikh FH, Ravichandran AK, Goldstein DJ, Agarwal R, Ransom J, Bansal A, Kim G, Cleveland JC, Uriel N, Sheridan BC, Chomsky D, Patel SR, Dirckx N, Franke A, Mehra MR. Impact of Race on Clinical Outcomes After Implantation With a Fully Magnetically Levitated Left Ventricular Assist Device: An Analysis From the MOMENTUM 3 Trial. Circ Heart Fail 2021; 14:e008360. [PMID: 34525837 DOI: 10.1161/circheartfailure.120.008360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heart failure disproportionately affects Black patients. Whether differences among race influence outcomes in advanced heart failure with use of a fully magnetically levitated continuous-flow left ventricular assist device remains uncertain. METHODS We included 515 IDE (Investigational Device Exemption) clinical trial patients and 500 Continued Access Protocol patients implanted with the HeartMate 3 left ventricular assist device in the MOMENTUM 3 study (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3). Outcomes were compared between Black and White left ventricular assist device recipients for the primary end point of survival free of disabling stroke or reoperation to replace or remove a malfunctioning device at 2 years, overall survival, adverse events, 6-minute walk distance, and quality of life scores. RESULTS Of 1015 HeartMate 3 patients, 675 were self-identified as White and 285 as Black individuals. The Black patient cohort was younger, more obese and with a history of hypertension, and more nonischemic cause of heart failure, relative to the White patient group. Black and White patients did not experience a difference in the primary end point (81.1% versus 77.9%; hazard ratio, 1.08 [95% CI, 0.76-1.54], P=0.6568). Black patients were at higher risk of adverse events (calculated as events per 100 patient-years), including bleeding (75.4 versus 63.5; P<0.0001), stroke (9.5 versus 7.2; P=0.0183), and hypertension (10.1 versus 3.2; P<0.0001). The 6-minute walk distance was not different at baseline and 6 months between the groups, however, the absolute change from baseline was greater for White patients (median: +183.0 [interquartile range, 42.0-335.3] versus +163.8 [interquartile range, 42.3-315.0] meters, P=0.01). The absolute quality of life measurement (EuroQoL group, 5-dimension, 5-level instrument visual analog scale) at baseline and 6 months was better in the Black patient group, but relative improvement from baseline to 6 months was greater in White patients (median: +20.0 [interquartile range, 5.0-40.0] versus +25.0 [interquartile range, 10.0-45.0]; P=0.0298). CONCLUSIONS Although the survival free of disabling stroke or reoperation to replace/remove a malfunctioning device at 2 years with the HM 3 left ventricular assist device did not differ by race, Black HeartMate 3 patients experienced a higher morbidity burden and smaller gains in functional capacity and quality of life when compared with White patients. These findings require efforts designed to better understand and overcome these gaps through systematic identification and tackling of putative factors. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02224755 and NCT02892955.
Collapse
Affiliation(s)
- Farooq H Sheikh
- Medstar Heart and Vascular Institute, Washington, DC (F.H.S.)
| | | | | | | | - John Ransom
- Baptist Health, Heart and Transplant Institute, Little Rock, AR (J.R.)
| | | | - Gene Kim
- University of Chicago Medical Center, IL (G.K.)
| | | | - Nir Uriel
- New York Presbyterian and Columbia University (N.U.)
| | | | | | | | - Nick Dirckx
- Global Biometrics, Abbott, Plymouth, MN (N.D.)
| | - Abi Franke
- Global Clinical Affairs - Heart Failure, Abbott, Sylmar, CA (A.F.)
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, MA (M.R.M.)
| |
Collapse
|
31
|
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
| |
Collapse
|
32
|
Chouairi F, Fuery M, Clark KA, Mullan CW, Stewart J, Caraballo C, Clarke JD, Sen S, Guha A, Ibrahim NE, Cole RT, Holaday L, Anwer M, Geirsson A, Rogers JG, Velazquez EJ, Desai NR, Ahmad T, Miller PE. Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation. J Am Heart Assoc 2021; 10:e021067. [PMID: 34431324 PMCID: PMC8649228 DOI: 10.1161/jaha.120.021067] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P<0.05). Over the study period, the proportion of Black and Hispanic patients listed for transplant increased: 21.7% to 28.2% (P=0.003) and 7.7% to 9.0% (P=0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84-0.90; P<0.001), but had a higher risk of post-transplant death (aHR, 1.14; CI, 1.04-1.24; P=0.004). There were no differences in transplantation likelihood or post-transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups (P<0.05). However, Black patients still had a lower likelihood of transplantation than White patients (aHR, 0.90; CI, 0.79-0.99; P=0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post-transplantation death.
Collapse
Affiliation(s)
- Fouad Chouairi
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | - Michael Fuery
- Department of Internal MedicineYale School of MedicineNew HavenCT
| | | | | | - James Stewart
- Division of Cardiac SurgeryYale School of MedicineNew HavenCT
| | - Cesar Caraballo
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | | | - Sounok Sen
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | | | | | | | - Louisa Holaday
- Department of Internal MedicineYale School of MedicineNew HavenCT
- Yale National Clinicians Scholar ProgramNew HavenCT
| | - Muhammed Anwer
- Division of Cardiac SurgeryYale School of MedicineNew HavenCT
| | - Arnar Geirsson
- Division of Cardiac SurgeryYale School of MedicineNew HavenCT
| | | | - Eric J. Velazquez
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | - Nihar R. Desai
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | - Tariq Ahmad
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
| | - P. Elliott Miller
- Section of Cardiovascular MedicineYale School of MedicineNew HavenCT
- Yale National Clinicians Scholar ProgramNew HavenCT
| |
Collapse
|
33
|
Sandhu AT, Tisdale RL, Rodriguez F, Stafford RS, Maron DJ, Hernandez-Boussard T, Lewis E, Heidenreich PA. Disparity in the Setting of Incident Heart Failure Diagnosis. Circ Heart Fail 2021; 14:e008538. [PMID: 34311559 PMCID: PMC9070116 DOI: 10.1161/circheartfailure.121.008538] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting. METHODS We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians. RESULTS Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10-1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16-1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors. CONCLUSIONS A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.
Collapse
Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine (A.T.S., F.R., D.J.M., E.L., P.A.H.), Stanford University, CA
| | - Rebecca L Tisdale
- Veteran's Affairs Palo Alto Healthcare System, CA (R.L.T., P.A.H.).,Stanford Health Policy, Centers for Health Policy/Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, CA (R.L.T.)
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine (A.T.S., F.R., D.J.M., E.L., P.A.H.), Stanford University, CA.,Stanford Prevention Research Center, Stanford University School of Medicine, CA (F.R., R.S.S., D.J.M.)
| | - Randall S Stafford
- Stanford Prevention Research Center, Stanford University School of Medicine, CA (F.R., R.S.S., D.J.M.)
| | - David J Maron
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine (A.T.S., F.R., D.J.M., E.L., P.A.H.), Stanford University, CA.,Stanford Prevention Research Center, Stanford University School of Medicine, CA (F.R., R.S.S., D.J.M.)
| | - Tina Hernandez-Boussard
- Department of Medicine (R.S.S., T.H.-B.), and Department of Biomedical Data Sciences (T.H.-B.), Stanford University, CA
| | - Eldrin Lewis
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine (A.T.S., F.R., D.J.M., E.L., P.A.H.), Stanford University, CA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine (A.T.S., F.R., D.J.M., E.L., P.A.H.), Stanford University, CA.,Veteran's Affairs Palo Alto Healthcare System, CA (R.L.T., P.A.H.)
| |
Collapse
|
34
|
Modi K, Pannu AK, Modi RJ, Shah SD, Bhandari R, Pereira KN, Kubra KT, Raval MR, Ajibawo T. Utilization of Left Ventricular Assist Device for Congestive Heart Failure: Inputs on Demographic and Hospital Characterization From Nationwide Inpatient Sample. Cureus 2021; 13:e16094. [PMID: 34367750 PMCID: PMC8330485 DOI: 10.7759/cureus.16094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives The first goal of the study is to provide a descriptive overview of the utilization of left ventricular assist device (LVAD) for the treatment of congestive heart failure (CHF) and determine the rates of LVAD use stratified by patients' demographic and hospitals' characteristics in the United States. Next, is to measure the hospitalization outcomes of length of stay (LOS) and cost in inpatients managed with LVAD. Methods We conducted a cross-sectional study using the nationwide inpatient sample and included 184,115 patients (age ≥65 years) with a primary discharge diagnosis of hypertensive and non-hypertensive CHF and was further classified by inpatients who were managed with LVAD. We compared the distributions of demographic and hospital characteristics in CHF inpatients with versus without LVAD by performing Pearson's chi-square test for categorical variables, and independent sample t-test for continuous variables. Results The inpatient utilization of LVAD was 0.93% (1690 out of 184,115) in CHF patients. The LVAD cohort were younger compared to non-LVAD group (mean age, 69.9 years vs. 79.4 years). The utilization rate of LVAD was also almost four times higher in males (1.50%) compared to females (0.36%). Although whites (78.5%) accounted for majority of LVAD recipients, the rate of LVAD utilization was highest in blacks (1.04%) and lowest in Hispanics (0.58%) with whites having utilization rate of 0.89%. Medicare was the dominant primary payer to cover the LVAD inpatients (91.1%), though the rate of LVAD utilization is highest in private (2.22%) and lowest in those covered by public insurance (medicaid/medicare). CHF patients in public hospitals (1.79%) were more than twice more likely to receive LVAD than in private hospitals (0.83%) due to higher utilization rate. LVAD utilization rate was approximately 55 times higher in teaching hospitals (1.67%) compared to non-teaching hospitals (0.03%), and 20 times higher in large bed hospitals (1.41%) compared to small bed-size hospitals (0.07%). CHF patients that received LVAD had a significantly longer LOS (34.6 days vs 9.8 days) and higher inpatient treatment costs ($802,118 vs. $86,302) compared to non-LVAD group. Conclusion The inpatient utilization of LVAD was in CHF patients is higher in males, blacks and private health insurance beneficiaries. In terms of hospital characteristics, the utilization of LVAD for CHF management was higher in large bed sized, and public type and teaching hospitals compared to their counterparts. This data will allow us to devise strategies to improve LVAD utilization and increase its outreach for heart failure patients, especially those on the transplant waiting list. Despite its effectiveness, aggressive usage of LVAD is restricted due to cost-effectiveness and lack of technical confidence among medical professional due to complications.
Collapse
Affiliation(s)
- Karnav Modi
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Amanpreet K Pannu
- Medicine, Sri Guru Ram Das University of Health Sciences, Amritsar, IND
| | - Ronak J Modi
- Cardiology, Bankers Heart Institute, Vadodara, IND
| | - Suchi D Shah
- Internal Medicine, Ahmedabad Municipal Corporation's Medical Education Trust Medical College, Ahmedabad, IND
| | - Renu Bhandari
- Medicine, Manipal College of Medical Sciences, Kaski, NPL
| | | | | | - Maharshi R Raval
- Internal Medicine, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Temitope Ajibawo
- Internal Medicine, Brookdale University Hospital Medical Center, New York City, USA
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
Stacy J, Khazanie P. Health Insurance and Left Ventricular Assist Device Outcomes: Focus on the Patient Journey, Not the Destination. Circ Heart Fail 2021; 14:e008558. [PMID: 33993720 PMCID: PMC8133467 DOI: 10.1161/circheartfailure.121.008558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John Stacy
- Department of Medicine, The University of Colorado School of Medicine, Aurora, CO
| | - Prateeti Khazanie
- Division of Cardiology, Department of Medicine, The University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
37
|
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.
Collapse
|
38
|
Khatana SAM, Grandin EW, Rame JE, Shen C, Yeh RW, Groeneveld PW. Medicaid Expansion and Ventricular Assist Device Implantation: An Analysis of the INTERMACS Registry. J Am Coll Cardiol 2021; 76:1501-1502. [PMID: 32943168 DOI: 10.1016/j.jacc.2020.07.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/08/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
|
39
|
Flint K, Chaussee EL, Henderson K, Breathett K, Khazanie P, Thompson JS, Mcilvennan CK, Larue SJ, Matlock DD, Allen LA. Social Determinants of Health and Rates of Implantation for Patients Considering Destination Therapy Left Ventricular Assist Device. J Card Fail 2020; 27:497-500. [PMID: 33346077 DOI: 10.1016/j.cardfail.2020.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/29/2020] [Accepted: 12/08/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND A left ventricular assist device (LVAD) is a treatment option available to select patients with advanced heart failure. However, there are important social determinants of health that can play a role in determining patients' outcomes after device placement. METHODS AND RESULTS We leveraged the DECIDE-LVAD Trial to assess social determinants of health-relationship status, household income, race/ethnicity, educational attainment, and health insurance-at the time of evaluation, and their association with rate of LVAD placement in the subsequent year. About a quarter of patients were unpartnered (i.e., single/divorced/widowed/separated; n = 55 [26%]). A similar proportion had a household income of less than $20,000 per year (n = 50 [24%]). Few patients were other race (n = 39 [18%]), had less than a high school education (n = 14 [6.6%]), or had Medicaid as their primary payor (n = 17 [8.4%]). LVAD implantation was significantly lower among patients who were unpartnered compared with patients who were married or partnered. LVAD implantation was not associated with income, race, educational attainment or insurance status. CONCLUSIONS Our data from diverse LVAD centers at U.S. private and academic hospitals found that, among a broad sample of patients being evaluated for LVAD, married or partnered status was favorably associated with LVAD implantation, but other social determinants of health were not. Future research and policy changes should consider novel interventions for improving access to LVAD implantation for patients with inadequate social support.
Collapse
Affiliation(s)
- Kelsey Flint
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Erin L Chaussee
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kamal Henderson
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado; Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Khadijah Breathett
- Division of Cardiology, Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Prateeti Khazanie
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jocelyn S Thompson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Colleen K Mcilvennan
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado
| | - Larry A Allen
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
40
|
Patel SA, Krasnow M, Long K, Shirey T, Dickert N, Morris AA. Excess 30-Day Heart Failure Readmissions and Mortality in Black Patients Increases With Neighborhood Deprivation. Circ Heart Fail 2020; 13:e007947. [PMID: 33161734 DOI: 10.1161/circheartfailure.120.007947] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Longstanding racial disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. We examined whether neighborhood environment modifies the disparity in 30-day HF readmissions and mortality between Black and White patients in the Southeastern United States. METHODS We created a geocoded retrospective cohort of patients hospitalized for acute HF within Emory Healthcare from 2010 to 2018. Quartiles of the Social Deprivation Index characterized neighborhood deprivation at the census tract level. We estimated the relative risk of 30-day readmission and 30-day mortality following an index hospitalization for acute HF. Excess readmissions and mortality were estimated as the absolute risk difference between Black and White patients within each Social Deprivation Index quartile, adjusted for geographic clustering, demographic, clinical, and hospital characteristics. RESULTS The cohort included 30 630 patients, mean age 66 years, 48% female, 53% Black. Compared with White patients, Black patients were more likely to reside in deprived census tracts and have higher comorbidity scores. From 2010 to 2018, 29.4% of Black and 23.0% of White patients experienced either a 30-day HF readmission or 30-day death (P<0.001). Excess in composite 30-day HF readmissions and mortality for Black patients ranged from 3.9% (95% CI, 1.5%-6.3%; P=0.0002) to 6.8% (95% CI, 4.1%-9.5%; P<0.0001) across Social Deprivation Index quartiles. Accounting for traditional risk factors did not eliminate the Black excess in combined 30-day HF readmissions or mortality in any of the neighborhood quartiles. CONCLUSIONS Excess 30-day HF readmissions and mortality are present among Black patients in every neighborhood strata and increase with progressive neighborhood socioeconomic deprivation.
Collapse
Affiliation(s)
- Shivani A Patel
- Emory Rollins School of Public Health, Atlanta, GA (S.A.P., K.L.)
| | - Maya Krasnow
- University of Chicago Pritzker School of Medicine, Chicago, IL (M.K.)
| | - Kaitlyn Long
- Emory Rollins School of Public Health, Atlanta, GA (S.A.P., K.L.)
| | - Theresa Shirey
- Department of Medicine, (T.S.), Emory University, Atlanta, GA
| | - Neal Dickert
- Division of Cardiology, (N.D., A.A.M.), Emory University, Atlanta, GA
| | - Alanna A Morris
- Division of Cardiology, (N.D., A.A.M.), Emory University, Atlanta, GA
| |
Collapse
|
41
|
Abstract
Although care of patients with heart failure (HF) has improved in the past decade, important disparities in HF outcomes persist based on race/ethnicity. Age-adjusted HF-related cardiovascular disease death rates are higher for Black patients, particularly among young Black men and women whose rates of death are 2.6- and 2.97-fold higher, respectively, than White men and women. Similarly, the rate of HF hospitalization for Black men and women is nearly 2.5-fold higher when compared with Whites, with costs that are significantly higher in the first year after HF hospitalization. While the relative rate of HF hospitalization has improved for other race/ethnic minorities, the disparity in HF hospitalization between Black and White patients has not decreased during the last decade. Although access to care and socioeconomic status have been traditional explanations for the observed racial disparities in HF outcomes, contemporary data suggest that novel factors including genetic susceptibility as well as social determinants of health and implicit bias may play a larger role in health outcomes than previously appreciated. The purpose of this review is to describe the complex interplay of factors that influence racial disparities in HF incidence, prevalence, and disease severity, with a highlight on evolving knowledge that will impact the clinical care and address future research needs to improve HF disparities in Blacks.
Collapse
Affiliation(s)
- Aditi Nayak
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.N., A.A.M.)
| | - Albert J Hicks
- Division of Cardiology, Baylor Scott & White, Temple, TX (A.J.H.)
| | - Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (A.N., A.A.M.)
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Yee RH, Knapp SM, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Association of Gender and Race With Allocation of Advanced Heart Failure Therapies. JAMA Netw Open 2020; 3:e2011044. [PMID: 32692370 PMCID: PMC7412827 DOI: 10.1001/jamanetworkopen.2020.11044] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Importance Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. Objective To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. Design, Setting, and Participants In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. Exposure Randomization to clinical vignettes. Main Outcomes and Measures Thematic differences in allocation of advanced therapies by patient race and gender. Results Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. Conclusions and Relevance This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.
Collapse
Affiliation(s)
- Khadijah Breathett
- Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
| | - Natalie Pool
- College of Nursing, University of Arizona, Tucson
| | - Megan Hebdon
- College of Nursing, University of Utah, Salt Lake City
| | | | - Ryan H Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson
| | - Sade Solola
- Department of Medicine, University of Arizona, Tucson
| | - Luis Luy
- University of Rochester, New York
| | | | - Leanne Zabala
- Department of Medicine, University of California, Los Angeles
| | - Jeff Stone
- Department of Psychology, University of Arizona, Tucson
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences, University of Arizona, Tucson
| | - Nancy K Sweitzer
- Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
| |
Collapse
|
44
|
Wang X, Luke AA, Vader JM, Maddox TM, Joynt Maddox KE. Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes. Circ Cardiovasc Qual Outcomes 2020; 13:e006284. [DOI: 10.1161/circoutcomes.119.006284] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between sex, race/ethnicity, insurance coverage, and neighborhood income and access to/outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did versus did not expand Medicaid.
Methods and Results:
Retrospective cohort study using State Inpatient Databases to identify patients 18 to 85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012 to 2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925 770 patients were included; 3972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted odds ratio [aOR], 0.45 [0.41–0.49]), black patients (aOR, 0.83 [0.74–0.92]), and Hispanic patients (aOR, 0.74 [0.64–0.87]) were less likely to receive LVADs than whites. Medicare (aOR, 0.79 [0.72–0.86]), Medicaid (aOR, 0.52 [0.46–0.58]), and uninsured patients (aOR, 0.17 [0.11–0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher income areas (aOR, 0.71 [0.65–0.77]). Among those who received LVADs, women (aOR, 1.78 [1.38–2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR, 1.97 [1.42–2.74]), and uninsured patients (aOR, 4.86 [1.92–12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation.
Conclusions:
There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.
Collapse
Affiliation(s)
- Xiaowen Wang
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (X.W.)
| | - Alina A. Luke
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
| | - Justin M. Vader
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
| | - Thomas M. Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
- Healthcare Innovation Lab, BJC HealthCare/Washington University School of Medicine, St. Louis, MO (T.M.M.)
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (X.W., A.A.L., J.M.V., T.M.M., K.E.J.M.)
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO (K.E.J.M.)
| |
Collapse
|
45
|
Breathett KK, Knapp SM, Wightman P, Desai A, Mazimba S, Calhoun E, Sweitzer NK. Is the Affordable Care Act Medicaid Expansion Linked to Change in Rate of Ventricular Assist Device Implantation for Blacks and Whites? Circ Heart Fail 2020; 13:e006544. [PMID: 32233662 DOI: 10.1161/circheartfailure.119.006544] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) has been associated with increased heart transplant listings among blacks, who are disproportionately uninsured. It is unclear whether the ACA is also associated with increased ventricular assist device implantation in blacks. METHODS Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington DC, we analyzed 1157 patients from early-adopter states (ACA Medicaid expansion by January 2014) and 785 patients from nonadopter states (no implementation from 2013 to 2014). Piecewise Poisson regression with a discontinuity was used to estimate change in census-adjusted rates of ventricular assist device implants by race and ACA adopter status 1 year before and after January 2014. RESULTS Following the ACA Medicaid expansion, the proportional change in rate increased significantly among blacks from early adopter (1.40 [95% CI, 1.12-1.75], pre 0.57/100 000 to post-ACA 0.80/100 000) but not nonadopter states (1.25 [95% CI, 0.98-1.58], pre 0.40/100 000 to post-ACA 0.50/100 000). However, the early and nonadopter changes in implantation rates were not statistically different from each other (P=0.50). There were no immediate changes in whites in either state group following the ACA Medicaid expansion (early adopter, 1.12 [95% CI, 0.98-1.29], pre 0.27/100 000 to post-ACA 0.30/100 000; nonadopter, 0.98 [95% CI, 0.82-1.16], pre 0.27/100 000 to post-ACA 0.26/100 000). CONCLUSIONS Among eligible states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, the ACA was not associated with immediate changes in ventricular assist device implantation rates by race. Although a significant increase in implantation rate was observed among blacks from early-adopter states, the change was not statistically different from the change seen in nonadopter states.
Collapse
Affiliation(s)
- Khadijah K Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center (K.K.B., N.K.S), University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute (S.M.K.), University of Arizona, Tucson
| | - Patrick Wightman
- Center for Population Sciences (P.W., E.C.), University of Arizona, Tucson
| | - Archita Desai
- Division of Gastroenterology, Indiana University, Indianapolis (A.D.)
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville (S.M.)
| | - Elizabeth Calhoun
- Center for Population Sciences (P.W., E.C.), University of Arizona, Tucson
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center (K.K.B., N.K.S), University of Arizona, Tucson
| |
Collapse
|
46
|
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: 2] [Impact Index Per Article: 0.5] [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
| |
Collapse
|
47
|
Durable mechanical circulatory support device use in the United States by geographic region and minority status. J Thorac Cardiovasc Surg 2019; 161:123-133.e13. [PMID: 31761344 DOI: 10.1016/j.jtcvs.2019.09.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/03/2019] [Accepted: 09/12/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Durable mechanical circulatory support device (MCSD) therapy has experienced rapid dissemination in the United States. Few studies have evaluated geographic patterns of its dissemination based upon patient characteristics that could identify potential variation in its application. METHODS A combined Interagency Registry for Mechanically Assisted Circulatory Support and Medicare dataset identified durable MCSD implants from 2008 through 2014. MCSD implant rates were estimated using yearly US Census population data, estimated from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database and stratified by age, race, and United Network for Organ Sharing (UNOS) region. RESULTS Overall, 16,331 patients received an MCSD implant from 232 unique centers. Annual MCSD implant rate (per 1 million population) significantly increased in each UNOS region (absolute range of increase, 5.3-16.4) with UNOS Region 7 demonstrating the highest overall absolute rate (20.9) in 2014 and UNOS Region 11 demonstrating the greatest relative increase in rate (430.5%). Geographical differences in the rate of MCSD implants were observed among whites and minorities with higher rates of MCSD implants observed for minorities for nearly all UNOS regions across all years. Significantly greater relative increases in MCSD implants for minorities compared with whites were observed within UNOS Regions 2, 3, 6, 7, 8, 9, and 11 (P < .001). CONCLUSIONS Geographical differences exist in rates of MCSD implantation among whites and minorities. The reasons for these differences are unknown, but may reflect underlying differences in disease burden or disparities in access to heart transplantation and warrant further study.
Collapse
|
48
|
Shirey TE, Morris AA. Different Lenses for the Same Story: Examining How Implicit Bias Can Lead Us to Different Clinical Decisions for the "Same" Patient. J Am Heart Assoc 2019; 8:e014355. [PMID: 31707941 PMCID: PMC6915292 DOI: 10.1161/jaha.119.014355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
49
|
Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Knapp S, Larsen A, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Does Race Influence Decision Making for Advanced Heart Failure Therapies? J Am Heart Assoc 2019; 8:e013592. [PMID: 31707940 PMCID: PMC6915287 DOI: 10.1161/jaha.119.013592] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies. Methods and Results Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation. Conclusions Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.
Collapse
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Natalie Pool
- College of Nursing University of Arizona Tucson AZ
| | - Megan Hebdon
- College of Nursing University of Arizona Tucson AZ
| | | | - Shannon Knapp
- Statistics Consulting Lab Bio5 Institute University of Arizona Tucson AZ
| | - Ashley Larsen
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Sade Solola
- Department of Medicine University of Arizona Tucson AZ
| | - Luis Luy
- University of Rochester Rochester New York U.S
| | | | | | - Jeff Stone
- Department of Psychology University of Arizona Tucson AZ
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences University of Arizona Tucson AZ
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| |
Collapse
|
50
|
Commentary: Mechanical circulatory support variation in the United States. J Thorac Cardiovasc Surg 2019; 161:134. [PMID: 31699421 DOI: 10.1016/j.jtcvs.2019.09.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 11/22/2022]
|