‘Depressing’: MU study finds unequal treatment between Black and white heart patients
A University of Missouri study has revealed racial inequality in the way Black patients with advanced heart disease are treated, with potentially harmful results that can include getting kicked off heart transplant waiting lists.
The study focused on the use of a left ventricular assist device, or LVAD, a mechanical pump installed in the body that helps the heart circulate blood. In some cases it can be used while a patient waits for a new heart, acting as a temporary bridge to a transplant.
The MU research revealed differences between when Black and white heart patients received that help.
Medical sociologist Adrianne Frech and her colleagues found that Black patients were more likely than white patients to receive an LVAD later in their disease. The result? Black patients were more likely to be deemed ineligible for a transplant and taken off the waiting list.
“Our initial supposition was that because we know that these disparities are so pervasive, Black patients must be getting unequal access to new technology. And that wasn’t true,” said Frech, an associate professor in the MU School of Health Professions.
“Black patients were getting the same access to newer technology, but they were getting it when they were sicker.”
The MU study provides yet more evidence of persistent inequities afflicting Black patients. Like others studying these ongoing health disparities, Frech and her colleagues called for more research into why they persist — what Harvard researcher Dr. David S. Jones calls “the million dollar question.”
“I’m not surprised at all — race disparities in care are pervasive, and usually in the direction of Blacks getting worse care or delayed care, as seen here,” said Jones, professor of epidemiology at Harvard’s T.H. Chan School of Public Health who researches the causes and meanings of health inequalities.
Jones said the MU study “provides yet another depressing piece of evidence that this is pervasive.”
Jones was senior author of a paper published last year in the New England Journal of Medicine that examined diagnostic tools and guidelines doctors consult in deciding treatment for patients.
Many algorithms were based on a patient’s race or ethnicity — propagating “race-based medicine” that could direct more resources to white patients than to others.
At the time, Jones told The New York Times that “we need to get off this train” of what, in effect, is racial profiling in medicine.
Though other research has described how implicit racial bias can influence the decision to place a patient on a transplant wait list, the MU study did not address that, said Frech’s fellow researcher Dmitry Tumin, an associate professor at Brody School of Medicine at East Carolina University.
Frech said their findings were “not shocking” and bore out the premise that inequality will always find a way to affect a person’s health. “The important thing is where is it, how much is there and which parts can we solve?” she said.
Whether racism has anything to do with it? That’s complicated.
Disparity at every stage
In 2018, a long-term study concluded that Black heart attack patients were less likely than white patients to receive aggressive medical procedures or certain medications given under common treatment guidelines.
The study, published in the Journal of the American Heart Association, examined data on 17,755 patients hospitalized between 2000 to 2014 in Maryland, North Carolina, Mississippi and Minnesota.
Researchers set out to find if disparities would improve over time.
They did not.
As a sociologist who studies inequalities in health, Frech became interested in the ever-improving technology of LVADs, wondering who gets the newest? Who does new technology help the most?
“Newest is better for a couple of reasons,” she said. “Newest is smaller, so more types of bodies can have an LVAD. Newest is more durable, so they last longer and help your body better.”
An LVAD can be used in many ways for people who have had a heart attack, cardiomyopathy — diseases of the heart muscle — or severe heart failure. For non-transplant candidates, it can be a temporary bridge to recovery for some with reversible heart failure, as well as a longer-term solution for others.
Frech and her colleagues analyzed the data of more than 5,500 heart patients across the country from the United Network for Organ Sharing, or UNOS, for the years 1999 to 2014.
UNOS is the private, nonprofit group that manages the nation’s organ transplant system — the national waiting list and data on every transplant in the United States.
There’s still much to know about how racial disparities between Black and white patients affect those waiting for and undergoing heart transplants, researchers wrote.
Timing is critical to the success of LVAD therapy. Installing them in stable patients “is considered superior to implantation later in the disease course, in ‘crash and burn’ patients,” researchers wrote.
They found that while Black patients were equally or more likely than white patients to receive newer-generation LVADs, that access “did not result in a narrowing of race differences in waiting list outcomes. In part, this was due to differences in the timing of medical intervention.”
Black candidates were 27% more likely than white patients to be removed from the transplant list because they became too sick to be eligible for a new heart. Age, gender and length of time on the list were also factors in being removed.
Though Black patients often delay seeking medical care, that was not a factor in the treatment disparity, Frech said.
“The thing is, the Black-white disparity exists at every stage of the heart failure process,” she said. “Black patients are more likely to have heart failure. They’re sicker once they come to a cardiologist, and they experience worse outcomes on the waiting list.
“We do know that Black patients tend to delay care. But for the variables we’re including, what we’re tapping into is that Black patients were more likely to get a drug instead of a device when they presented with heart failure.”
The study found that Black patients often were given inotropes — medicines that change the heart’s contractions — “instead of a device, while white patients were able to get an LVAD before they were so sick they had to be on the heart transplant waiting list.”
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Insurance makes a difference
Researchers also said insurance coverage played a role in this unequal treatment. Patients with Medicare and Medicaid, which was more common among Black transplant candidates, were 40% more likely to be removed from the transplant list.
Research in 2019 presented to the American Heart Association showed that patients who are Black or Hispanic, uninsured or covered by Medicaid, and living in low-income ZIP codes were less likely to receive an LVAD.
“Considering lack of coverage, it is very rare for patients to be listed for transplantation without insurance coverage, because transplant teams want to ensure that donor organs go to patients who are able to keep up with the expensive post-transplantation immunosuppression regimen,” said Tumin.
Frech said a step in the right direction came in December when the Centers for Medicare and Medicaid Services updated coverage criteria for the devices that will make them available to more Medicare patients.
“The previous policy was that if you were on public insurance, you couldn’t have an LVAD until you needed a heart transplant. They wouldn’t reimburse for it,” said Frech. “And Black patients are more likely to have public insurance.”
Her study calls for researchers to investigate whether public policies like that can inadvertently harm the neediest patients.
Is it racism?
“There are certainly many ways in which the system is stacked against Black patients, whether it’s differences in insurance status (as in this study), differences in the location and quality of hospitals (minority patients often end up at lower quality hospitals), etc.,” said Jones.
Racial inequalities can happen without anyone trying to be racist, said Frech.
“So, if you’re — and this doesn’t come directly from the study, I’m just supposing — a physician who knows that a Black patient is more likely to delay care, have a harder time keeping up with their meds, have a harder time managing their LVAD device, you might be more likely to give them inotropes (medications) because you think it’s the best way to help them in that moment.
“The problem is if you’re attributing that need for extra help to their Blackness rather than to their clinical presentation, then you’re more likely to give a Black patient a drug instead of a device in a way that shows up at the population level, in a way that maintains health disparities.
“It doesn’t have to do with a physician being racist or acting racist.”
On the other hand, she said, “I don’t think you can present this information to a patient and tell them it’s not about racism. Again, just like you can’t tell physicians they’re being racist, you can’t tell patients that this isn’t racism, because it’s structural racism.”
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