COMMENTARY

Stepping Up to Achieve Health Equity in Heart Failure

Alanna A. Morris, MD, MSc, FACC, FAHA, FHFSA; Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA

Disclosures

September 07, 2022

Editorial Collaboration

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This transcript has been edited for clarity.

Alanna A. Morris, MD, MSc, FACC, FAHA, FHFSA: My name is Dr Alanna Morris, and I'm an associate professor of medicine in the Division of Cardiology at Emory University School of Medicine in Atlanta, Georgia. I'm excited today to be joined by my friend and colleague, Dr Khadijah Breathett.

Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA: My name is Dr Khadijah Breathett. I'm a heart failure transplant cardiologist, physician scientist, and tenured associate professor of medicine at Indiana University Health. My work focuses on reducing racial, ethnic, and gender disparities in heart failure.

Morris: Khadijah, this is exciting because we both are physician scientists that investigate and are trying to reduce the impact of healthcare disparities on patients with heart failure, whom we care for every day.

Let me start with some introductory comments. We know the burden of heart failure is on the rise. It's well described as the leading cause of hospitalization in older adults over the age of 65 years. However, we're also starting to see an increased number of publications that highlight the burden of premature-onset heart failure, and by premature, I mean heart failure that occurs in persons under the age of 65 years.

Importantly, within both the older and the younger age groups, the burden of heart failure, unfortunately, varies substantially by race and ethnicity, with Black Americans having the highest risk for early-onset disease, as well as other underrepresented racial and ethnic groups like Hispanic Americans and American Indians. Of course, we know that the risk for hospitalizations once heart failure manifests is also higher in those underrepresented racial and ethnic groups.

You and I both know that there's really an increased emphasis by healthcare systems on reducing the burden of hospitalizations among our patients with heart failure, coupled with this recent reckoning in the medical community to both acknowledge the role of structural racism and social determinants of health as drivers of adverse outcomes for patients with chronic disease. This has appropriately prompted a call for increased awareness of how we can address healthcare disparities as practicing clinicians.

Dr Breathett, we're at a point as heart failure clinicians where we really have much to offer patients to improve morbidity and mortality, but we know that not all patients are getting this optimal care. What do you see as the most pressing issues right now related to achieving equity in heart failure care?

Breathett: There are two parts to this issue — one of which is recognizing that this is real. There's still, I'd say, a schism among healthcare professionals who believe that this isn't important; that all they need to do is prescribe medications; and that other people should worry about social determinants of health, bias, and structural racism. And I think there is a greater proportion of people that recognizes that that is far from the case, and that we have to address these issues if we want to achieve quality care.

A second part of this issue is to move beyond just talking about the stats year after year, as they continue to worsen, and to start acting to change our behavior and the way our healthcare systems work so that we can achieve a different outcome from what we've had in the past.

Addressing Drug Costs and Social Determinants of Health

Morris: I think those are both excellent points. As clinicians, we're trained to follow guidelines, to prescribe medications, to try to improve outcomes, and yet we know that even adherence to those guidelines and who gets certain medications differ across racial and ethnic groups. For example, in heart failure, we now know that, for heart failure with reduced ejection fraction (HFrEF), quadruple therapy is standard of care and is considered foundational care.

We know that many of those newer medications are quite costly. There have been some recent analyses that have shown that the median out-of-pocket costs for quadruple therapy is about $94 per month, and over the course of the year, that annual cost exceeds $2200. This is driven primarily by the high cost of angiotensin receptor-neprilysin inhibitor (ARNI) and sodium-glucose co-transporter 2 (SGLT2) inhibitors.

Is this an issue for patients from underrepresented racial and ethnic groups? Is this more so an issue of socioeconomic status? How should we be thinking about these issues when we're prescribing or trying to adhere to guideline-directed medical therapy among our patients with heart failure?

Breathett: Cost is a major issue. If we're not addressing this with patients, we can't expect that they're going to get these treatments that save their lives. That's incredibly naive. We have to start having these conversations with patients as part of shared decision-making where we're willing to discuss costs and how these different therapies might impact them. Some of this is going to clearly go beyond what the individual clinician can do. This is a system- and policy-level issue.

I think this is going to require healthcare professionals and patients to act as political advocates, speak to our politicians, write letters, and speak up to insurance companies to let them know that the way things are going is insufficient, inappropriate, and leads to inadequate care. We have to do a better job of identifying how we can get these wonderful therapies that work well for patients to the patients who need them most.

I'm not saying that everybody has to have the same fee system, but for those that can't afford it or for whom it's more difficult, we need to have a different fee system in place. The current ones, as you know, are mostly helpful for people with private types of insurance with the patient assistance plans. They are not based on the needs of people with lower incomes who may have a more difficult time paying for these medications.

Morris: That's exactly right. For our Medicare patients, especially, oftentimes their out-of-pocket costs for these medications go up astronomically. You and I probably see that every day in clinic when we listen to our patients describe their difficulties with financial considerations. Even beyond drugs, we've seen some really interesting data with device-based therapies and transcatheter-based therapies, where unfortunately, geographic location and neighborhood also seem to be drivers of the dramatic disparities that we see in terms of who's getting those therapies.

We know, for example, when you look at some of the transcatheter aortic valve replacement (TAVR) data that patients of color, Black patients in particular, are much less likely to get TAVR services, and there have been some recent analyses that have shown that neighborhood may be one of the drivers. Intuitively, we realize that our large structural programs that offer these types of interventions tend to really only be located in large academic or large wealthy hospitals and are very rarely located in safety net hospitals or smaller community centers where Black and Brown patients are more likely to receive their care. How do we address issues such as these?

Breathett: In the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, there was actually a class I recommendation for addressing care for vulnerable populations, indicating that we have to look at our system, we have to address what we are doing from a multidisciplinary standpoint to allocate therapies equitably to our patients. We have to address social determinants of health, we have to address bias, and we have to establish metrics that we measure as individuals and as a system. We've seen at even our highly rated academic centers that the care is still inequitable.

I've done a national study showing that you're less likely to get care by a cardiologist if you're Black race vs White, and this is [in over 100,000] patients at hundreds of hospitals, representing well over 20% of the US. Another study shows that within one of the top institutions in the country, they see these same findings, where Black patients go to one service and the White patients go to the cardiology service. It's a very deeply ingrained issue that we have to recognize. Yes, structural racism exists, and we have to determine what we're going to do to try to address it.

The Role of Healthcare Practitioners

Morris: When we talk about structural racism, we also have to think about what our responsibility is as clinicians caring for patients. All of us work hard and we are under a large amount of stress, particularly as we've been trying to implement healthcare during this ongoing pandemic. It's hard for many of us to think that perhaps we're caring for patients from certain groups differently and there may be a role of bias.

What has your work taught us about how clinicians might be aware of their own biases when they're caring for patients? More importantly, how can we overcome those biases so that we can be delivering equitable care across different demographic groups?

Breathett: The majority of healthcare practitioners think they're doing the right thing, or they think that, yes, bias is present, but not in my care, not in our system, when in fact it is.

You helped be a part of this national study that we did looking at how clinicians, nurses, and social workers make decisions about who should get advanced therapies, randomizing them to assess a Black man or a White man with identical clinical and social histories — unbeknownst to them. The point was to figure out how race impacts our decision-making.

We did think-aloud, step-by-step interviews and identified that, yes, race actually impacts how people make decisions and that Black people aren't given the benefit of the doubt. Black people are judged more harshly. Black people die. This is from people who, I don't think, would believe in their hearts that they could be a part of that system, but they are.

We have to start to use some of the structured methods to address these biases, like evidence-based bias reduction training and evidence-based anti-racism reduction, using objective measures that quantify things like adherence and social support so that we can start to tease away and remove the levels of bias and structural racism that impact these life-changing decisions for our patients.

It's hard work, and it's something I'm incredibly passionate about, and I'm leading a national, pragmatic, randomized, controlled trial to try to address this. It's definitely hard work. I think we need more studies like this that use implementation science using different strategies to try to address these known disparities so we can actually change them instead of talking about the stats year after year.

Advocating for Change

Morris: We've talked about a couple of the key stakeholders, including clinicians and healthcare systems, that really have to embrace anti-racism, equity, and health equity as core values. Across the current political landscape, what can we do as societies? How should we be engaging our policymakers to improve health equity? Again, this is an issue that crosses many different levels within healthcare and certainly goes beyond the patient-clinician relationship.

Breathett: There are multiple ways to get involved. Just at an individual level, it's looking at how you provide care and talking to the patient. Finding out what's troubling them, what their barriers are, and identifying resources within your center to help address the barriers per person. Make it individualized.

From a system level, within the healthcare system, meet with the leaders and those who are in charge of the resources to identify, how can you create resources for patients who need them? Every hospital system has some wiggle room for how they allocate resources. It's important to show hospitals how it's cost-saving and improves the quality level to address these issues, that this is the right thing to do for our patient population.

I think from a community level and policy level, we have to start engaging with stakeholders, those who are community leaders that care about this, and to meet and decide how we can collectively make changes within our healthcare system, within our city, and within our state to improve the care of our patients.

The more we build momentum by having these conversations, with letter-writing campaigns to our policymakers, and being proactive with our different cardiovascular associations, such as the American College of Cardiology (ACC), American Heart Association (AHA), and Association of Black Cardiologists (ABC), that we'll be able to have a collective voice to demonstrate the need for action and the need for change. I think policymakers listen to the voice of their constituents.

Morris: Well, thank you, Dr Breathett. Your wisdom in this space has been incredibly valuable. I'm excited to see what's next in terms of your work. I'm excited for you to continue to teach us how we can improve health equity and how we can do this better as clinicians, scientists, and healthcare systems.

Breathett: Thank you so much.

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