Decision making in advanced heart failure therapy allocation is subject to bias by race, sex, and ethnicity, a study of group dynamics has found.
The challenges of appropriately and equitably applying advanced HF therapies to a diverse population have been recognized by several studies. Often a team of medical experts is involved in decision making in this setting, and so group dynamics may contribute to disparities in therapeutic allocation based on race, sex, and ethnicity.
To investigate this interaction further, Khadijah Breathett, MD, MS, and colleagues developed a prospective mixed-methods study drawing from four US advanced heart therapy centers, the results of which were published in the Journal of the American Heart Association. Dr. Breathett discussed these findings with Physician’s Weekly.
PW: Why did you feel this topic warranted exploration?
Dr. Breathett: In a study of over 400 healthcare professionals representing transplant regions across the US, we found that allocation decision making was influenced by who was in the room. Allocation meetings were described as undemocratic and hierarchical. This suggested that group dynamics may play a role in how decisions are made. To improve the allocation process and make it more equitable, we had to understand how group dynamics impact the allocation of advanced HF therapies. We searched the literature for the best standardized metrics to measure group dynamics and found the de Groot Critically Reflective Diagnoses Protocol. I reached out to Dr. de Groot to understand more about this metric. My team reviewed the manuscripts describing this method, and we used this standardized tool to measure group dynamics of allocation meetings for four US heart transplant centers. We were able to measure group dynamics and ensure rigor by including two independent qualitative analysts who were blinded to patient demographics and participant demographics.
What are the most significant findings from the study?
We found a statistically significant relationship between group dynamics and the allocation decision. Better group dynamics were associated with a greater likelihood of recommending advanced therapies to women (Figure). Worse group dynamics were associated with a greater likelihood of recommending advanced therapies to men. This is important since women do not receive advanced therapies at the rate that would be expected for their level of disease. Several studies have indicated that women are less than half as likely to receive advanced therapies than men when referred for advanced therapies. This study highlights an intervenable area that may address gender disparities in advanced therapy allocation.
How can these findings be incorporated into practice?
Any discipline could use this tool to evaluate their group dynamics and reassess dynamics following an intervention.
What still needs to be explored?
We developed an intervention called the SOCIAL HF (Seeking Objectivity in Allocation of Advanced Heart Failure) therapies trial. We piloted this intervention, including evidence-based bias reduction and antiracism training (adapted from the Bias Reduction in Internal Medicine program by Dr. Molly Carnes), instruction on using more objective metrics for social support, and instruction on improving group dynamics. This study revealed feasibility in implementation and showed signals for improved group dynamics and culture.
I am leading a randomized controlled cluster trial/implementation science type 2 study to improve the allocation of advanced HF therapies among 14 heart transplant centers in the US. We are using this tool to measure changes in group dynamics across control and treatment centers over time. The SOCIAL HF study is being funded by the National Heart, Lung, and Blood Institute and will be completed in a few years.
Is there anything else that Physician’s Weekly readers should know about your research?
When we see these repetitive and worsening disparities, it is important to search for the why. Try to understand what and how the fundamental etiologies contribute to the problem. Then work to develop stakeholder and theory-informed strategies and interventions to correct these etiologies.
