Disparities in Left Ventricular Assist Device Implantation Based on Race, Sex

Between 2007 and 2015, Medicare beneficiaries with heart failure (HF) who are Black or female were less likely to receive a left ventricular assist device (LVAD) implantation, according to research published in JAMA Network Open.

Specifically, Black beneficiaries were 3% less likely to receive an LVAD compared with White beneficiaries, and female patients with HF were 7.9% less likely to have an LVAD implanted compared with male patients.

“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,” the authors said.

To come to these findings, the authors conducted a retrospective cohort study of 12,310 Medicare beneficiaries who were admitted to a hospital for HF between 2008 and 2014. They collected data from Medicare fee-for-service administrative claims between July 2007 and December 2015, and analyzed them between August 2020 and May 2022.

Of this group of beneficiaries, 2819 (22.9%) were Black and 2920 (23.7%) were women.

Multivariable models demonstrated that Black beneficiaries hospitalized for HF were between 0.2% and 5.8% less likely to receive an LVAD than White beneficiaries, and women were between 5.6% and 10.2% less likely to receive an LVAD than men.

The study also showed that experiencing poverty and worse neighborhood deprivation were associated with a 2.9% and 6.7% reduced use of LVAD, respectively.

Additionally, racial disparities were concentrated among patients with a propensity score less than 0.52. One-year survival rates were similar on average based on race and sex, but Black patients with a low propensity score experienced improved survival by 7.2% (95% CI, 0.9%-13.5%).

However, according to the authors, clinical characteristics and social determinants of health did not explain disparities based on race or sex.

“The treatment and post-LVAD survival by race were equivalent among the most obvious LVAD candidates,” they wrote. “However, there was differential use and outcomes among less clear-cut LVAD candidates, with lower use but improved survival among Black patients.”

While the authors noted that restricted information in Medicare claims data poses a major limitation in the study, they also argued these disparities are very unlikely related to differences in HF risk or severity or differences in clinician and patient preferences based on race or sex.

The authors concluded that a potential link between LVAD implantation and both neighborhood and individual poverty warrants further research.

However, ultimately, the authors argued that disproportionate differences in LVAD use based on race and sex are a result of systemic racism, which can be tied to income inequality and unequal LVAD access.

“Approaches toward addressing sex inequities may include prioritizing adequate representation in clinical trials among those designing and enrolling and the funding of mixed methods research aimed at understanding reasons for and methods to address sex inequality,” the authors wrote.

Reference

Cascino TM, Somanchi S, Colvin M, et al. Racial and sex inequities in the use of and outcomes after left ventricular assist device implantation among Medicare beneficiaries. JAMA Netw Open. Published online July 27, 2022. doi:10.1001/jamanetworkopen.2022.23080