种族不平等在考虑护理偏好后仍然存在于心室辅助装置和移植的获得中：REVIVAL 研究的报告。
Racial Inequities in Access to Ventricular Assist Device and Transplant Persist After Consideration for Preferences for Care: A Report From the REVIVAL Study.
机构信息
Division of Cardiovascular Disease (T.M.C., M.M.C., K.D.A.), University of Michigan, Ann Arbor.
Henry Ford Hospital, Detroit, MI (D.E.L.).
出版信息
Circ Heart Fail. 2023 Jan;16(1):e009745. doi: 10.1161/CIRCHEARTFAILURE.122.009745. Epub 2022 Oct 19.
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
URL: https://www.
CLINICALTRIALS
gov; Unique identifier: NCT01369407.
背景
尽管导致心力衰竭（HF）患者获得先进治疗的种族差异的原因尚不确定，但种族差异在获得 HF 治疗中心治疗的 HF 患者接受心室辅助装置（VAD）和移植的机会方面得到了充分的记录。我们旨在确定种族对 VAD 中心接受治疗的患者使用 VAD 和移植的影响，并确定患者的偏好是否会影响这一效果。
方法
我们对在 21 个 VAD 中心接受 VAD 治疗且无 VAD 禁忌证的慢性收缩性 HF 患者进行了一项观察性队列研究，这些患者在 VAD 中心接受门诊治疗，并在 REVIVAL 研究（VAD 门诊生活中重要信息的登记评估）中进行了为期 2 年的随访。我们使用竞争事件特定比例风险方法和多重插补来处理缺失数据。主要结局包括（1）VAD/移植和（2）死亡。感兴趣的暴露因素包括种族（黑人或白人）、其他人口统计学特征、社会决定因素健康、临床医生评估的 HF 严重程度、患者报告的生活质量、对 VAD 的偏好和对治疗的渴望。
结果
该研究纳入了 377 名参与者，其中 100 名（26.5%）为黑人。VAD 或移植在 11 名（11%）黑人患者和 62 名（22%）白人患者中进行，尽管 18 名（18%）黑人患者和 36 名（13%）白人患者死亡。黑人种族与 VAD 和移植的使用减少相关（调整后的危险比为 0.45 [95%CI，0.23-0.85]），但死亡风险并未增加。种族之间对 VAD 或维持生命治疗的偏好相似，并且不能解释种族差异。
结论
在接受 VAD 中心高级 HF 心脏病专家治疗的患者中，尽管黑人患者的 HF 严重程度、生活质量和社会决定因素健康状况相似，但黑人患者接受 VAD 和移植的比例较低，尽管他们的治疗偏好相似。这种剩余的不公平可能是结构种族主义和歧视或影响决策的提供者偏见的结果。
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