Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association

Abstract

Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.

Keywords: AHA Scientific Statements; health disparities; health equity; heart failure; heart transplant; implementation science; pragmatic clinical trials as topic; race factors; women’s health.

Figure.. Close the HF equity and implementation gaps by lowering the drawbridge.

The open drawbridge represents the heart failure (HF) equity and implementation gaps between underrepresented racial and ethnic groups receiving evidence-based HF treatments. Drawbridges work by initiation of cogwheels on each side of the bridge that allow both sides of the bridge to open and close. An open drawbridge contributes to increasing HF morbidity and mortality, particularly for underrepresented racial and ethnic groups. The HF equity and implementation gaps may be closed by simultaneously starting the gears to lower the drawbridge on both sides of the bridge. This includes the following steps: (1) identify HF equity and implementation gaps; (2) engage diverse stakeholders; (3) select equity framework and implementation framework that consider equity; (4) identify barriers and facilitators to equitable treatment for HF; (5) use implementation strategies with target, temporality, and dose; and (6) assess equity measures for success. SDOH indicates social determinants of health.