Women, Minority Patients with Advanced Heart Failure Less Likely to Receive LVAD Devices

Jeffrey McCullough, PhD

Despite being associated with improved quality of life and longevity, new research suggests women and minority patients with heart failure were less likely than their male and White counterparts to receive left ventricular assist devices (LVAD).

An analysis of claims data from Medicare beneficiaries admitted with heart failure from 2008-2014, results of the study indicate female patients were 7.9% less likely to receive LVAD than their male counterparts and Black patients 3.0% less likely to receive LVAD than White beneficiaries, with investigators noting these disparities were not fully explained by clinical characteristics or social determinants of health.

“These findings suggest that there is less aggressive use of LVADs for Black and female Medicare beneficiaries, likely resulting from differences in clinician decision-making because of systemic racism and discrimination, implicit bias, or patient preference,” wrote investigators.

With a multitude of trials and studies outlining the benefits of LVADs on survival among patients with advanced heart failure, outline pitfalls in strategies for optimization of use can have a significant role on patient- and population-level health. To explore potential barriers to implantation among Medicare beneficiaries, a team from Michigan Medicine led by Jeffrey McCullough, PhD, an associate professor of Health Management and Policy at Michigan Medicine, conducted a retrospective cohort study using claims data from Medicare Fee-for-Service administrative claims from July 2007-December 2015.

Seeking to include all Medicare Fee-for-Service beneficiaries hospitalized with systolic heart failure from 2008-2014 with at least 6 months of continuous enrollment prior to hospitalization, investigators identified 311,265 patients for potential inclusion in their study. Of these, 12,310 were identified as having an LVAD use probability of at least 5%. The primary outcomes of interest for the study were the receipt of LVAD and 1-year mortality. The secondary outcome of interest was 30-day readmissions. Outcomes of interest were assessed using logistic regression models. Specifically, 9 different models were used to assess post-LBAD survival differences, with each model further adjusting for covariates. Exposures of interest for these analyses were beneficiary race and sex.

Of the 12,310 patients identified for inclusion, 48.0% received an LVAD. Initial analysis indicated LVAD use was higher among White and male patients, with these differences maintained across the LVAD propensity distributions. Further analysis suggested Black beneficiaries were 3.0% (95% CI, 0.2-5.8%) less likely to receive LVAD than White beneficiaries, and women were 7.9% (95% CI, 5.6-10.2%) less likely to receive LVAD than men after adjustment for clinical characteristics, distance from a center, individual poverty, and neighborhood-level social deprivation. When assessing 1-year survival rates among LVAD recipients, investigators found the 1-year survival rate was 76% among Black recipients and 72% among White recipients. For male and female patients, the equivalent survival rates were 72% and 73%, respectively.

“For clinicians, the finding of reduced LVAD use for Black patients suggests that implicit biases or personally mediated racism impact decision-making. Both implicit biases, which refer to the unconscious attitudes that impact our actions, and personally mediated racism, referring to conscious or unconscious discrimination in the form of differential actions according to race, have been shown to influence the quality of care,” investigators added.

This study, “Racial and Sex Inequities in the Use of and Outcomes After Left Ventricular Assist Device Implantation Among Medicare Beneficiaries,” was published JAMA Network Open.