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    Original Investigation
    July 21, 2020

    Association of Gender and Race With Allocation of Advanced Heart Failure Therapies

    Author Affiliations
    • 1Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
    • 2Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
    • 3College of Nursing, University of Arizona, Tucson
    • 4College of Nursing, University of Utah, Salt Lake City
    • 5Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson
    • 6Department of Medicine, University of Arizona, Tucson
    • 7University of Rochester, New York
    • 8University of Arizona Medical School, Tucson
    • 9Department of Medicine, University of California, Los Angeles
    • 10Department of Psychology, University of Arizona, Tucson
    • 11Center for Population Health Sciences, University of Arizona, Tucson
    JAMA Netw Open. 2020;3(7):e2011044. doi:10.1001/jamanetworkopen.2020.11044
    Key Points español 中文 (chinese)

    Question  Is bias against a patient’s gender and race associated with the allocation of advanced heart failure therapies?

    Findings  In a qualitative study of 46 health care professionals, there was more bias against women compared with men when evaluating appearance and social support, particularly among African American women. Final recommendations were not different for groups defined by gender or race; all were offered ventricular assist devices rather than transplantation during interviews.

    Meaning  Although gender and race were not associated with allocation of advanced heart failure therapies in this study, there was evidence of bias, which could contribute to delayed and lower allocation of advanced therapies to women.


    Importance  Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women.

    Objective  To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies.

    Design, Setting, and Participants  In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests.

    Exposure  Randomization to clinical vignettes.

    Main Outcomes and Measures  Thematic differences in allocation of advanced therapies by patient race and gender.

    Results  Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients.

    Conclusions and Relevance  This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.