Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study
Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study
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在考虑护理偏好后，使用心室辅助装置和移植的种族不平等现象依然存在： REVIVAL研究报告
DOI：
10.1161/circheartfailure.122.009745
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发表时间：
2023-01-01
影响因子：
9.7
通讯作者：
Aaronson, Keith D.
中科院分区：
文献类型：
--
作者：
Cascino, Thomas M.;Colvin, Monica M.;Aaronson, Keith D.
背景：心力衰竭（HF）患者在获得先进治疗方面的种族差异已被充分记录，尽管原因仍不确定。我们试图确定种族之间的关联，利用心室辅助装置（VAD）和移植的患者在VAD中心获得护理，如果患者的喜好影响effect.Methods：我们进行了一项观察性队列研究的非卧床慢性收缩期HF患者的高风险功能，并没有禁忌症，VAD参加了21个VAD中心和随访2年的REVIVAL研究（注册评估的重要信息VAD在门诊生活）。我们使用竞争事件的原因特异性比例风险方法，对缺失数据进行多重插补。主要结局为（1）VAD/移植和（2）死亡。感兴趣的风险包括种族（黑色或白色），额外的人口统计学，捕获的社会健康决定因素，临床医生评估的HF严重程度，患者报告的生活质量，对VAD的偏好，和治疗的愿望。结果：该研究包括377名参与者，其中100（26.5%）确定为黑色。在11名（11%）黑人和62名（22%）白色参与者中进行了VAD或移植，尽管18名（18%）黑人和36名（13%）白色参与者死亡。黑人与VAD和移植的使用减少相关（校正的风险比，0.45 [95%CI，0.23-0.85]），而死亡率没有增加。偏好VAD或维持生命的治疗是相似的种族，并没有解释种族差异。结论：在VAD中心接受护理的先进HF心脏病专家的患者中，即使在调整HF严重程度，生活质量和健康的社会决定因素后，尽管相似的护理偏好，黑人患者的VAD和移植的利用率仍较低。这种残余的不平等可能是结构性种族主义和歧视或影响决策的提供商偏见的结果。注册：
Background:Racial disparities in access to advanced therapies for heart failure (HF) patients are well documented, although the reasons remain uncertain. We sought to determine the association of race on utilization of ventricular assist device (VAD) and transplant among patients with access to care at VAD centers and if patient preferences impact the effect.Methods:We performed an observational cohort study of ambulatory chronic systolic HF patients with high-risk features and no contraindication to VAD enrolled at 21 VAD centers and followed for 2 years in the REVIVAL study (Registry Evaluation of Vital Information for VADs in Ambulatory Life). We used competing events cause-specific proportional hazard methodology with multiple imputation for missing data. The primary outcomes were (1) VAD/transplant and (2) death. The exposures of interest included race (Black or White), additional demographics, captured social determinants of health, clinician-assessed HF severity, patient-reported quality of life, preference for VAD, and desire for therapies.Results:The study included 377 participants, of whom 100 (26.5%) identified as Black. VAD or transplant was performed in 11 (11%) Black and 62 (22%) White participants, although death occurred in 18 (18%) Black and 36 (13%) White participants. Black race was associated with reduced utilization of VAD and transplant (adjusted hazard ratio, 0.45 [95% CI, 0.23-0.85]) without an increase in death. Preferences for VAD or life-sustaining therapies were similar by race and did not explain racial disparities.Conclusions:Among patients receiving care by advanced HF cardiologists at VAD centers, there is less utilization of VAD and transplant for Black patients even after adjusting for HF severity, quality of life, and social determinants of health, despite similar care preferences. This residual inequity may be a consequence of structural racism and discrimination or provider bias impacting decision-making.Registration: