Findings of a US investigation of clinician race and gender bias in decision-making around heart failure therapies suggests that African American women may be judged more harshly by appearance and adequacy of social support than their peers. Published in JAMA: Network Open the study by Khadijah Breathett (University of Arizona, Tucson, USA) et al concluded that it is possible that race and gender bias may contribute to delayed allocation of these therapies.
“Heart failure therapies are inequitably allocated to minority racial groups in the US,” Breathett et al note in the introduction to the study, noting that previous research has found that despite African American individuals being the highest racial risk group for heart failure incidence and mortality, they are less likely to receive defibrillators and care by a cardiologist compared with white individuals.
In order to determine whether patient gender and race impacts the decision-making of clinicians during the allocation of advanced heart failure therapies, Breathett and colleagues interviewed 46 US members of the International Society for Heart and Lung Transplant (ISHLT) at the 2019 ISHLT scientific sessions. Participants were randomised to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men). Vignettes described patients with end-stage heart failure with complex history, including multiple relative contraindications for advanced therapies, with gender and race indicated by photographs, text, and names associated with ethnic or gender identity. The four study photographs included an African American woman, a white woman, an African American man, and a white man.
Participants were interviewed about their decision-making process and asked how each section of the vignette influenced their recommendation for advanced heart failure therapies. Interviews were analysed using grounded theory methodology. Supplemental surveys were provided to participants after completing interviews in which participants were asked to rate how each section of the vignette influenced the patient’s suitability for advanced heart failure therapies.
The study team found that among the 46 participants (24 [52%] women, 20 [43%] racial minority), clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Additionally, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Furthermore, the study team observed more concern regarding appropriateness of prior care of the African American woman compared to the white woman, while there were greater concerns about adequacy of social support for the women than for the men. 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.
“Additional steps can be taken to reduce the influence of bias during advanced heart therapy allocation,” Breathett and colleagues write in their analysis of the findings. “As demonstrated in this study, healthcare professionals had altruistic plans for each patient, but patient gender and race influenced the decision-making process. Bias reduction training may create a culture of equity for patients with advanced heart failure, particularly among individuals with a desire to parallel their behavior with their belief systems.
“Bias training has been effective in reducing implicit bias and changing behaviour among healthcare professionals. Small systemic changes may also improve health equity. Participants in this study identified patient photographs and descriptions of children as potential sources of bias. Steps can be taken to avoid including these data during routine presentations of candidates for advanced therapies.”
Breathett et al note that the study is limited by the use of a single clinical vignette for each patient group which does not represent the full spectrum of possible clinical presentations, and noted that the study included a small number of participants focused on vignettes of men patients and was not designed to have an equal number of vignettes by gender.
In conclusion, Breathett et al note that bias related to patient gender and race was present in the process of allocating advanced heart failure therapies, with women patients, particularly African American women, judged more harshly for their appearance and degree of social support than men of both races with identical clinical and social histories. Bias related to gender and race could lead to delayed allocation and inequity in patient outcomes, they note, adding that further investigation and implementation of bias reduction strategies are needed.