Racial bias and discrimination may negatively impact heart disease care, risk factors

Racial and ethnic minorities are often disproportionately affected by heart disease and stroke. Subtle racial bias may creep into the decision-making process for approving black patients with heart failure for a heart transplant and African immigrants who have experienced discrimination are more likely to have three or more heart disease and stroke risk factors, according to two studies to be presented at the American Heart Association's Scientific Sessions 2019—November 16-18 in Philadelphia.

Does race influence decision-making for advanced heart failure therapies? (Oral Presentation 114)

In a first of its kind study, simultaneously published in the Journal of the American Heart Association, the open access journal of the American Heart Association, researchers at the University of Arizona, Tucson, explored whether health care professionals' decision-making processes may contribute to racial disparities in heart failure treatment.

Researchers asked 422 physicians, nurses and other hospital decision-makers to determine whether hypothetical black male and white male patients should be referred for a heart transplant after reviewing patient photos and other patient health information. The hypothetical cases had identical medical and social history; race was the only variant.

When surveyed individually, there were few racial differences in recommendations for transplants. However, when a subgroup of 44 reviewers discussed the cases—a situation which more closely resembled actual advanced therapy selection meetings than a survey—researchers found racial bias. The reviewers perceived black patients as less healthy than whites, less likely to comply with follow-up care recommendations and less trustworthy. Thus, black patients were more likely to be recommended for ventricular assist devices than heart transplants, especially if the health care provider was over the age of 40.

"African-American race negatively influenced the decision-making process for heart transplants, especially during discussions among health care providers," said lead author Khadijah Breathett, M.D., M.S., an assistant professor of medicine and advanced heart failure/transplant cardiologist at the University of Arizona's Sarver Heart Center. "Since advanced therapy selection meetings are conversations rather than surveys, race may contribute significantly to treatment recommendations."

Breathett is a member of the American Heart Association's Heart Failure & Transplantation Committee, Leadership Committee for Quality of Care and Outcomes Research and Social Determinants of Health Committee.

AHA volunteer expert Kiarri N. Kershaw, Ph.D., MPH, said this was a "strong study and really important for people, clinicians and others to really understand how implicit bias can kind of creep into decision-making, and how it can have an important impact on outcomes."

Kershaw, an associate professor of Preventive Medicine (Epidemiology) at Northwestern University Feinberg School of Medicine in Chicago is also a member of the American Heart Association's Quality of Care and Outcomes Research and Social Determinants of Health Committee.

"The most important thing is to recognize that implicit bias is real, and it's pervasive and that clinicians really need to look within and really think about whether or not they have implicit biases and how those might be influencing their decisions," she said. "The first step is to be aware and acknowledge that you yourself might be biased, and these biases might be influencing you and try and seek ways to address it."

Breathett is a finalist for the Samuel A. Levine Early Career Clinical Investigator Award for this work.

Discrimination is associated with high cardiovascular disease risk: The African Immigrant Health Study (Poster Presentation Sa3062)

In an unrelated study, researchers found that African immigrants who reported more experience of discrimination have more cardiovascular disease risk factors. However, this connection does not prove that discrimination caused the increase in cardiovascular risk factors.

Previous studies have shown that increased discrimination is associated with increased heart disease and stroke risk among African Americans; however, there is no data on African immigrants, according to lead study author Ruth-Alma Turkson-Ocran, Ph.D. Turkson-Ocran is an American Heart Association Strategically Focused Obesity Research Network post-doctoral fellow at Johns Hopkins University in Baltimore.

Researchers surveyed a cross-section of 395 African immigrants living in the Baltimore-Washington, D.C. Metropolitan, area and found that participants who reported having frequent experiences of discrimination were almost twice as likely to have higher risk for heart disease or three or more heart disease risk factors.

Discrimination was linked to an increase in three or more heart disease risk factors: high blood pressure, elevated cholesterol, diabetes, poor diet, smoking and being overweight or obese. Cardiovascular risk continued to remain elevated after considering income (more than 80% of the participants had an annual income over $40,000), education levels (more than 60% had a college degree), health insurance (only 67% reported having any insurance) and length of time in the country (nearly half had lived in the United States 15 years or longer).

"Understanding and acknowledging the relationship between discrimination and heart disease risk is important considering that African immigrants are vulnerable to suboptimal heart health. As we found, like their African American counterparts, African immigrants are more likely to encounter discrimination in the health care setting," Turkson-Ocran said. "This is a necessary first step to addressing bias within health care, and with increased awareness, may facilitate a culture where health care is provided with cultural humility."

Turkson-Ocran also said the results indicate the need for more culturally appropriate outreach and interventions specifically targeting this group.

Kershaw said this study is "striking" and "really shows how discrimination can influence a variety of different race and ethnic groups or people of different backgrounds, and the lasting impact it can have on your health."