Does Intersection of Racial, Gender Biases Affect Heart Failure Treatment Decisions?

The authors of a recent study in JAMA Network Open report that although racial bias is a known contributing factor to uneven distribution of several methods of advanced heart failure treatments (eg, transplants and ventricular assist devices [VADs]), the extent to which the intersection of opinions on gender and race may also influence decision making in the field remains unknown.

A commentary on their findings even pointed out that heart failure starts earlier in African American patients compared with white patients, and that the men in this patient group have the highest age-adjusted death rate for heart failure per 100,000 individuals at 118.2 vs 111.3 in non-Hispanic white men, 86.0 in African American women, and 80.4 in white women.

The qualitative study involved April 2019 interviews with, and supplemental surveys of, 46 US clinicians (all members of the International Society for Heart and Lung Transplantation [ISHLT]) that took place at ISHLT scientific sessions. These participants were purposely diverse, having been chosen based on their gender, race, geography, and years past training. They first were randomized to review the clinical vignettes of patients with heart failure, and the interviews and surveys followed. Most (52%) of the clinicians were women, and 43% were racial minorities.

There were 20 vignettes each on white and African American women, and 3 each on white and African American men. These vignettes were identical, varying only by gender and race, and all included pictures. They also were randomized in 2 ways:

• 1:1 by African American to white patients
• 20:3 by female to male patients

“[This was done] to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients,” the authors stated.

Their results demonstrate the link that may exist when gender and race intersect in heart failure. Overall, there were 5 principal findings:

1. Female patients’ appearance was more harshly criticized compared with the male patients, focusing on the women’s age, weight, hair, makeup, and facial expressions.
2. African American men were thought to have more severe illness, while women in both groups had equal degrees of illness.
3. Prior care may have been inappropriate more often for African American vs white women, although women overall seemed to receive inadequate care.
4. Women may receive less social support than men, especially African American women for whom children, family dynamics, and finances were deemed “greater concerns.” Children were considered a liability.
5. VADs were recommended more often compared with heart transplants.

These results were reached by the authors who used the think-aloud method to uncover conscious and unconscious thoughts among their interviewees, as well as Shafer and Lohse cognitive interview prompts. They solicited opinions on each section of the vignettes and asked the clinicians for final treatment recommendations and why. Their findings also mirror results seen in several previous studies.

“Both patient gender and race were associated with bias in the decision-making process for heart transplantation allocation despite patients having identical case presentations,” the authors concluded. “Bias related to gender and race could lead to delayed allocation and inequity in patient outcomes. Further investigation and implementation of bias reduction strategies are needed.

They recommend investigations to gather multicenter data on how social determinants of health affect heart therapy allocation, bias reduction training to reduce implicit bias toward and treatment inequity among patients with heart failure, and education for patients so they know all of their treatment options, can advocate more often for themselves, and can collaborate with clinicians and other professionals on their care.

Reference

Breathett K, Yee E, Pool N, et al. Association of gender and race with allocation of advanced heart failure therapies. JAMA Network Open. 2020;3(7):e2011044. doi:10.1001/jamanetworkopen.2020.11044