By AMERICAN HEART ASSOCIATION NEWS
Despite a decade’s worth of research revealing racial and ethnic disparities among heart failure patients receiving an implantable defibrillator, things aren’t getting any better, according to a new study out this month.
The study, published in Circulation, included more than 21,000 heart failure patients admitted to top hospitals that have adopted the American Heart Association’s Get With The Guidelines-Heart Failure program that helps hospitals deliver better care. All patients were eligible for an implantable cardioverter defibrillator, a battery-powered device that shocks the heart should it start beating erratically.
Yet only about one in five patients were counseled about the option of receiving an ICD. Many of those left out of the conversation were blacks, Hispanics and women.
Among patients who were counseled, black and Hispanic patients were less likely than their white counterparts to get an ICD. The data show 65 percent of whites got the device or planned to get it, compared with 58 percent of blacks and 56 percent of Hispanics.
Researchers didn’t look at why the disparities exist, but they do say the inequities could be dangerous.
“Those patients, randomized clinical trials have shown, are more likely to live … if they get a defibrillator,” said cardiologist Deepak L. Bhatt, M.D., a study coauthor. “It’s a big deal whether a patient gets a defibrillator or not.”
Bhatt has this to tell colleagues: You need to do better.
“I think the most important message is one of education,” said Bhatt, a professor of medicine at Harvard Medical School and executive director of interventional cardiovascular programs at the Heart and Vascular Center at Boston’s Brigham and Women’s Hospital.
The study found that when doctors did talk to patients about ICDs, nearly two-thirds got or planned to get one.
A key finding is that women who talked to their doctors about an ICD are as likely as men to get it. That suggests “it’s the physician not advising or counseling that’s the issue,” said Bhatt.
One solution could be for hospitals to create a checklist that reminds doctors to discuss the risks and benefits of an ICD, Bhatt said. Although he doesn’t anticipate it will be challenging to get doctors to counsel more heart failure patients about the potential benefits of ICDs, training healthcare providers to educate all their patients may not be as simple.
The study authors said the differences among the gender and racial groups “may represent systemic biases.” For example, doctors may not offer ICDs to groups underrepresented in clinical trials that mostly involved white men, they wrote.
These latest findings give doctors “an opportunity for helping eliminate some disparities in care for women and those underrepresented minorities.”
Nearly 6 million Americans live with heart failure, and about half die within five years of diagnosis.
A next step for researchers, Bhatt said, is to look at why black and Hispanic patients given the option of an ICD are less likely than their white peers to get one. In conversations with colleagues, Bhatt is sometimes told patients from certain ethnicities are more reluctant to have surgeries such as the one required to implant the defibrillator.
“Part of that may be cultural issues, part of that might be sort of a fear of hospitals,” he said. “All patients are prone to those sorts of concerns, but it might be a little bit higher with certain cultural backgrounds.”
Cardiologist Paul Heidenreich, M.D., of the VA Palo Alto Health Care System, said the report is a “unique resource” because it is among the first large-scale studies to look at who is getting advised about the pros and cons of the defibrillator.
“Just having that data is a large step forward,” said Heidenreich, a professor of medicine and health research and policy at Stanford University’s School of Medicine, who was not involved in the study.
Although the differences in gender and race and ethnicity are important, too few patients are being counseled regardless of race or sex, Heidenreich said. “One could argue it [might] be more important to lift all boats.”
A more practical takeaway from the study is that “we should be documenting our discussions, particularly for important issues like ICD placement,” Heidenreich said. “Some of us may need to change our practice.”
Heart failure patients and families should also bring it up, said Heidenreich. “Just because something wasn’t addressed doesn’t mean the physician didn’t want to address it eventually.”