Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Nov 19;8(22):e013592.
doi: 10.1161/JAHA.119.013592. Epub 2019 Nov 11.

Does Race Influence Decision Making for Advanced Heart Failure Therapies?

Khadijah Breathett  1 , Erika Yee  2 , Natalie Pool  3 , Megan Hebdon  3 , Janice D Crist  3 , Shannon Knapp  4 , Ashley Larsen  2 , Sade Solola  5 , Luis Luy  6 , Kathryn Herrera-Theut  7 , Leanne Zabala  7 , Jeff Stone  8 , Marylyn M McEwen  3 , Elizabeth Calhoun  9 , Nancy K Sweitzer  1
Affiliations

Does Race Influence Decision Making for Advanced Heart Failure Therapies?

Khadijah Breathett et al. J Am Heart Assoc. .

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.

Keywords: decision making; healthcare delivery; healthcare disparities; heart failure; heart transplant.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Interview guide and survey questions. Warm‐up questions and helping participant with think aloud were from Shafer and Lohse instructions on cognitive interviewing.19
Figure 2
Figure 2
Decision‐making process for allocating advanced heart failure therapies. Themes from Grounded Theory of Think‐Aloud Interviews. GDMT indicates guideline‐directed medical therapy; LVAD, left ventricular assist device.
See this image and copyright information in PMC

Comment in

References

    1. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee . Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139:e56–e66. - PubMed
    1. Chan PS, Oetgen WJ, Buchanan D, Mitchell K, Fiocchi FF, Tang F, Jones PG, Breeding T, Thrutchley D, Rumsfeld JS, Spertus JA. Cardiac performance measure compliance in outpatients: the American College of Cardiology and National Cardiovascular Data Registry's PINNACLE (Practice Innovation And Clinical Excellence) program. J Am Coll Cardiol. 2010;56:8–14. - PMC - PubMed
    1. Farmer SA, Kirkpatrick JN, Heidenreich PA, Curtis JP, Wang Y, Groeneveld PW. Ethnic and racial disparities in cardiac resynchronization therapy. Heart Rhythm. 2009;6:325–331. - PubMed
    1. Breathett K, Liu WG, Allen LA, Daugherty SL, Blair IV, Jones J, Grunwald GK, Moss M, Kiser TH, Burnham E, Vandivier RW, Clark BJ, Lewis EF, Mazimba S, Battaglia C, Ho PM, Peterson PN. African Americans are less likely to receive care by a cardiologist during an intensive care unit admission for heart failure. JACC Heart Fail. 2018;6:413–420. - PMC - PubMed
    1. Breathett K, Allen LA, Helmkamp L, Colborn K, Daugherty SL, Khazanie P, Lindrooth R, Peterson PN. The Affordable Care Act Medicaid expansion correlated with increased heart transplant listings in African‐Americans but not Hispanics or Caucasians. JACC Heart Fail. 2017;5:136–147. - PMC - PubMed

Publication types