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In recent years, there has been a growing recognition of the wide range of health and healthcare disparities facing racial minority groups in the United States. Compared with White patients, for example, Black patients are more likely to have worse outcomes from various types of respiratory disease, cancer, and cardiovascular disease (CVD).1-3
Among reported cardiovascular disparities, studies consistently show a higher incidence and prevalence of heart failure (HF) among Black patients, who have higher mortality rates (up to 3-fold) and hospitalization rates compared with White patients with HF.3
Research published in JAMA Cardiology found the self-reported prevalence of HF between 2013 and 2016 was 3-fold higher among non-Hispanic Black adults aged 35-64 compared with non-Hispanic White adults of the same age range.4
In an observational study published in August 2020, Black race was linked to increased risk of incident HF hospitalization (hazard ratio [HR], 1.23; 95% CI, 1.09-1.40) in a sample of 25,790 patients who were followed for a median of 10.1 years, even after adjusting for traditional cardiovascular risk factors.5 These findings align with those of several previous studies.
Another 2020 study “found a persistent and widening black–white gap,” in rates of preventable hospitalizations for HF, with odds ratios that were 5.2-6.4 times higher among non-Hispanic Black adults than non-Hispanic White adults over a 7-year period in Connecticut.6
While awareness of these disparities is vital, experts emphasize that prompt action is needed to reduce the gaps. “Despite the ever-growing portfolio of scientific literature describing the existence of health disparities, the healthcare community continues to struggle to find viable methods to effectively eliminate disparities,” wrote Nayak et al in a 2020 review published in Circulation: Heart Failure.3
The complexity of issues influencing these disparities presents a substantial challenge to identifying and implementing solutions. “Still, we must meet that challenge head on,” emphasize Nayak et al, “by continuing to encourage research initiatives, quality metrics, clinical trial enrollment, reporting of results, as well as patient education and engagement that are sensitive to race and ethnic differences in the manifestations of CVD.”
For further discussion of these disparities and potential solutions, we interviewed Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA, advanced HF and transplant cardiologist and assistant professor of medicine in the division of cardiology at the University of Arizona College of Medicine in Tucson, Arizona, and Sabra C. Lewsey, MD, MPH, FACC, advanced HF and transplant cardiologist and assistant professor of medicine in the division of cardiology at Johns Hopkins University School of Medicine in Baltimore, Maryland, and board member of the Association of Black Cardiologists. Dr Breathett and Dr Lewsey coauthored a recent review on this topic that was published in Current Opinion in Cardiology.7
What key factors likely drive the disparities affecting Black patients with HF?
Dr Breathett: These come down to social determinants of health, bias, and structural racism. Each of these factors contributes to the burden of disease, [its] under-recognition [and] undertreatment, and unequal outcomes after diagnosis. If we are to change the trajectory of inequity in [HF] for Black patients, we must allocate our resources to address social determinants of health, bias, and structural racism.
What broad-level changes are needed to address these issues?
Dr Breathett: Diverse stakeholders need to come together to devise [meaningful] policy changes — from schools, to neighborhoods, to hospital structure. It will require immediate and long-term changes in local and federal policies. Fortunately, the process can be guided by science — specifically implementation science, a form of research that iteratively studies strategies to get optimal care to a population in a way that is immediate and lasting.8
How can individual clinicians and practices help to reduce these disparities?
Dr Lewsey: Clinicians and individual practices have a very important and necessary role in actualizing equitable HF care across communities. The data show us that guideline-directed HF therapies save lives! Clinicians and practices should focus intently on eliminating barriers to the consideration, initiation, and continuation of these life-saving therapies for their patients. This means being systematic in considering and periodically reconsidering [the individual patient’s] indications for guideline-directed HF therapies and interventions.
Furthermore, clinicians must partner with multidisciplinary community resources to leverage social work services, patient navigators, and pharmacy teaching as a part of comprehensive [HF] care. Clinicians must make time to gain insight into the daily life and social determinants impacting an individual patient’s health. Integral to this insight is a dialogue that builds a foundation of trust aided by culturally competent interactions. Diversification of the pipeline of clinicians and scientists to reflect the communities that they serve will be essential in this endeavor.9
What are the most pressing remaining needs in this area?
Dr Lewsey: The [HF] mortality disparity gap has widened over the last 18 years, and the impact of the COVID-19 pandemic on incident [HF] and worsening inequity remains to be realized. Strategically and intentionally addressing these disparities in real-time is of paramount importance. Targeted research addressing disparities solutions and community-wide implementation of guideline-directed [HF] therapy and prevention strategies must be resolutely pursued.
References
1. Ejike CO, Woo H, Galiatsatos P, et al. Contribution of individual and neighborhood factors to racial disparities in respiratory outcomes. Am J Respir Crit Care Med. 2021;203(8):987-997.
2. Zavala VA, Bracci PM, Carethers JM, et al. Cancer health disparities in racial/ethnic minorities in the United States. Br J Cancer. 2021;124(2):315-332. doi:10.1038/s41416-020-01038-6
3. Nayak A, Hicks AJ, Morris AA. Understanding the complexity of heart failure risk and treatment in Black patients. Circ Heart Fail. 2020;13(8):e007264. doi:10.1161/CIRCHEARTFAILURE.120.007264
4. Rethy L, Petito LC, Vu THT, et al. Trends in the prevalence of self-reported heart failure by race/ethnicity and age from 2001 to 2016. JAMA Cardiol. 2020;5(12):1425-1429.
5. Pinheiro LC, Reshetnyak E, Sterling MR, Levitan EB, Safford MM, Goyal P. Multiple vulnerabilities to health disparities and incident heart failure hospitalization in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. Circ Cardiovasc Qual Outcomes. 2020;13(8):e006438.
6. Doshi RP, Yan J, Aseltine RH Jr. Age differences in racial/ethnic disparities in preventable hospitalizations for heart failure in Connecticut, 2009-2015: A population-based longitudinal study. Public Health Rep. 2020;135(1):56-65.
7. Lewsey SC, Breathett K. Racial and ethnic disparities in heart failure: Current state and future directions. Curr Opin Cardiol. 2021;36(3):320-328.
8. Galaviz KI, Barnes GD. Implementation science opportunities in cardiovascular medicine. Circ Cardiovasc Qual Outcomes. 2021;14(7):e008109.
9. Kuehn BM. Association of Black Cardiologists calls for urgent effort to address health inequity and diversity in cardiology. Circulation. 2020;142(11):1106-1107. doi:10.1161/CIRCULATIONAHA.120.050130
