key: cord-0820671-jc757y6x
authors: Givens, Raymond C.
title: Are the current evaluation tools for advanced therapies biased?
date: 2021-03-12
journal: Curr Opin Cardiol
DOI: 10.1097/hco.0000000000000848
sha: 31c22577d0490d8c8a32ed7a1248630c1550344e
doc_id: 820671
cord_uid: jc757y6x

PURPOSE OF REVIEW: Despite attention to racial disparities in outcomes for heart failure (HF) and other chronic diseases, progress against these inequities has been gradual at best. The disparities of COVID-19 and police brutality have highlighted the pervasiveness of systemic racism in health outcomes. Whether racial bias impacts patient access to advanced HF therapies is unclear. RECENT FINDINGS: As documented in other settings, racial bias appears to operate in HF providers’ consideration of patients for advanced therapy. Multiple medical and psychosocial elements of the evaluation process are particularly vulnerable to bias. SUMMARY: Reducing gaps in access to advanced therapies will require commitments at multiple levels to reduce barriers to healthcare access, standardize clinical operations, research the determinants of patient success and increase diversity among providers and researchers. Progress is achievable but likely requires as disruptive and investment of immense resources as in the battle against COVID-19.

Decisions about whether a patient should receive advanced heart failure (HF) therapy, and which type -heart transplant (HT) or left ventricular assist device (LVAD) -require considering a complicated slate of risks and benefits. Whether the metrics HF practitioners use to evaluate patients for advanced therapy are universally appropriate, and whether therapies are distributed fairly, are areas that need discussion and investigation. The following review considers possible bias in evaluating patients for advanced therapy largely through the lens of American anti-Black racism and its consequences. I discuss the potential for biased risk estimates based upon standard assessments of medical and psychosocial factors, negative impacts of provider bias, and the need to be serious about addressing disparities and improving diversity in clinical research.

African-Americans and other marginalized groups bear a disproportionate burden of chronic diseases, including HF. From 2002 to 2013, age-standardized HF hospitalization rates for African-Americans were more than twice that for any other group [1] . Analysis of Centers for Disease Control data shows that age-adjusted excess Black HF deaths have decreased overall since the late 1960s, but over the past two decades have increased nearly twofold (Fig. 1A ) despite a cascade of landmark HF trials-erasing 30 years of progress. The crude excess Black HF death rate has increased since 1999 in every age group between 25 and 84 ( Fig. 1B) , ages in which HF patients might benefit from advanced therapies.

One-year post-HT survival is roughly comparable regardless of race, but Black recipients have higher long-term rates of death or graft failure in most United Network for Organ Sharing (UNOS) registry analyses [2] [3] [4] [5] , including that presented in Fig. 2 . Linked UNOS and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry data prior to HeartMate 3 LVAD (HM3) availability show superior survival for patients bridged to HT with an LVAD (BTT) than those receiving an LVAD as provisional destination therapy (DT) [3] . Survival after HM3 implantation in the MOMENTUM 3 trial was roughly 87% at 1 year and 79% at 2 years regardless of intent (BTT, DT, or bridge to candidacy) as compared to 90% and 85% one-and three-year post-HT survival, respectively [6] . LVAD implantation or HT should yield similar one-year survival for patients suitable for either strategy. However, while an LVAD can be implanted on-demand, time to HT depends upon multiple factors including ABO blood type, waitlist priority, UNOS region, pulmonary hypertension (HTN), sensitization, and body size. Only half of candidates have undergone HT by 1 year after listing, and roughly 22% have experienced death or delisting [7] . Compared to White BTT patients, African-Americans are more likely to die or be delisted and less likely to receive HT [2] . The 2018 revision to the UNOS heart allocation strategy additionally advantages patients on temporary mechanical circulatory support. In response, centers are bridging fewer

Despite advances in the management of various stages of heart failure, excess age-adjusted deaths among African-Americans have risen substantially over the past two decades.

Multiple elements of the advanced HF therapy evaluation process are vulnerable to bias.

The impact of biases on advanced therapy evaluation is unclear and requires dedicated research.

candidates with durable devices and more with temporary support [8] [9] [10] . Optimal strategies for supporting diverse patients with advanced HF in the current era of organ allocation and durable LVAD have not been explored.

Common indications for advanced therapy include intractable symptoms such as angina, manifestations of low cardiac output, and electrical or hemodynamic instability despite the maximum achievable pharmacologic and interventional therapy [11, 12] . Advanced HF programs must be prudent in evaluating how to allocate limited resources based upon patients' medical and psychosocial risk. But select elements of typical evaluation processes appear vulnerable to bias.

Several factors would predict a higher likelihood of Black patients being declined for advanced therapy or receiving an LVAD before or instead of HT. The distributions of these factors by race among patients evaluated for advanced therapies, prior to candidacy, are unclear. Additionally, data directly establishing their contribution to bias in the evaluation are lacking.

A higher prevalence of O blood type among Black and Latinx people in the general US population and on HT waitlists would predict longer wait times and thus higher LVAD placement rates than for White people [13, 14] . Patients who are sensitized against donor antigens may also require LVAD bridging until a suitable donor can be identified or appropriate desensitization is completed. But LVAD surgery conveys a risk of additional sensitization because of transfusion needs, and thus may further delay HT.

Morris et al. found in a UNOS registry analysis that Black candidates had higher peak panel reactive antibody (PRA) levels that predict graft failure, and are the most likely ethnic group to be sensitizeddefined as having peak PRA 10% [14] . Known contributors to sensitization did not appear to explain these differences. Black candidates were less likely than others to have previously received blood transfusions. Black candidates were more likely to have had prior pregnancies, but this difference appears to reflect the higher proportion of women among Black candidates than among other groups. Whether sensitization influences equity in the allocation of LVAD and HT is unexamined. Morris et al.

additionally showed in a single-center retrospective study that Black HT recipients were more likely to develop de novo donor-specific antibodies (DSAs), independently of pre-HT sensitization [15] . LVAD placement as a bridge to HT was marginally predictive of de novo DSA development.

Pulmonary vascular resistance (PVR) 3 Wood units (WU) is a common contraindication to HT. Perhaps owing to later referral, Black and Latinx candidates are more likely than White candidates to have a PVR >3 WU [16, 17] . If the PVR cannot be lowered pharmacologically, LVAD implantation may be considered until hemodynamics are more suitable for HT listing.

A peak oxygen consumption (VO 2 ) 14 mL/kg/ min on cardiopulmonary exercise testing is a wellknown indication for advanced therapy. Black HF patients have lower average peak VO 2 compared to White patients despite similar b-blocker use [18, 19] . This difference may reflect later referral, but peak VO 2 is lower for African-Americans without HF [20, 21] . Lower cardiorespiratory fitness among African-Americans is unexplained. Researchers have invoked lower hemoglobin levels and muscle oxidative capacity due to a lower abundance of mitochondria-rich type I muscle fibers, but race independently predicts peak VO 2 after adjustment for these factors among subjects without HF [22] [23] [24] . A higher prevalence of obesity and chronically lower access to physical activity opportunities for African-Americans may also be explanatory. Ventilatory efficiency, as indicated by the minute ventilation/carbon dioxide slope (VE/VCO 2 ), is strongly predictive of a combined endpoint of HT, LVAD, or cardiac death in multiple studies [25, 26] . Peak VO 2 was not significantly prognostic in a multicenter study for HF Black patients, particularly for Black women, but VE/VCO 2 appeared to be predictive regardless of race or sex [27] . Whether preferential use of VE/VCO 2 versus peak VO 2 would affect equity in advanced therapy deserves additional study.

Black HT candidates have a higher average body mass index (BMI) than other groups. Increasing BMI at listing predicts declining likelihood of HT, including nearly 50% reduction for candidates with BMI 35 [28] . Neither BMI at listing or at transplant predicts one-year post-HT survival, though highpriority recipients with BMI 35 have reduced three-year survival [28, 29] . Obesity is associated with elevated risks of non-HM3 LVAD thrombosis, device-related infection and right HF, but lower oneyear and equivalent two-year mortality [30] . For BTT patients, obesity, even at a BMI >40, does not predict post-HT survival despite higher risk profiles [31] . A single-center study found no impact of extreme obesity (BMI >40) on survival at one year after LVAD implantation, despite more pump thrombosis among obese patients [32] . Figure 3 shows J-shaped hazards of graft failure or death among first-time heart-only recipients as a function of BMI at listing-after adjustment for age, sex, UNOS region, year of transplant, and LVAD or right ventricular assist device (RVAD) at listing. The risk for Black patients rises at higher BMIs than for other groups and is only 10% above baseline at a BMI of 36. These differences mirror epidemiologic findings of ethnic-specific all-cause mortality hazards due to BMI [33, 34] .

BMI firmly associates with the risk of diabetes mellitus (DM), which is more prevalent among non-White people in the general population [35] . Despite a negative impact on a wide range of health outcomes, DM does not consistently associate with post-LVAD mortality, infection, stroke, or pump thrombosis [36] . A beneficial effect of LVAD placement on glucose metabolism may explain this null association [37, 38] . The impacts of DM and glycemic control on the allocation of advanced therapy by race are unclear.

Early chronic kidney disease (CKD) prevalence is similar among American ethnic groups but CKD progression is more common among non-White groups. Black, Latinx, and Indigenous Americans have a higher prevalence of end-stage renal disease (ESRD) than do White people [39] . In addition to likely socioeconomic contributors, elevated frequencies of high-risk apolipoprotein L1 gene alleles among African-Americans appear to explain a substantial proportion of excess ESRD risk [40] . In a prospective cohort, Black subjects with an estimated glomerular filtration rate (GFR) between 20 and 70 mL/min/1/73 m 2 were more likely to have HF at study entry and a 60% higher risk of HF events over a median follow-up of 6.6 years [41] . Among patients with established HF, CKD is more common among Black patients with HF with preserved ejection fraction than among White patients [42] . Black HT recipients are more likely than White recipients to have also received a simultaneous kidney transplant [43] . A small single-center retrospective study indicates greater declines in estimated GFR after solitary HT for Black recipients compared to non-Black recipients despite similar maintenance calcineurin inhibitor levels [44] . For patients with reduced GFR in the setting of HF, LVAD placement results in early improvement in renal function that returns to the pre-LVAD baseline after one year, for reasons that are unclear [45] . The degree to which advanced therapies affect renal disease progression among different ethnic groups deserves further study. Whether CKD has differential impact on advanced therapy candidacy by race is unknown. Recent debate that remains unsettled surrounds whether race should be included in the estimation of GFR. Both the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations incorporate Black race. Concerns that inclusion of race in clinical equations may be counterbalanced by underestimation of GFR for most African-Americans if the race parameter were to be removed [46] . The magnitude of difference is small for patients whose true GFR is lower than 30 [47] .

Standardized pretransplant psychosocial assessments have been tested in diverse cohorts [48] [49] [50] [51] [52] [53] . Each rates candidates in domains that include social support, psychological illness, and stability, readiness for therapy, illness management including adherence, and substance use. Each of these domains, perhaps excluding substance use, is vulnerable to bias. The abilities of these factors to predict advanced therapy outcomes are inconsistent, and whether they perform similarly for different ethnic groups is unclear.

Given a need for patients to adhere faithfully to heavy drug regimens after advanced therapy, nonadherence should raise concerns, especially for HT. There is evidence of less-consistent pill-taking among privately insured Black, Latinx, and Asian patients compared to White patients prescribed medications for HTN, DM, and hyperlipidemia after controlling for socioeconomic status and out-ofpocket costs [54] . At a large HF clinic, non-White patients were likelier to arrive late for appointments, but the effect was confined primarily to younger patients scheduled for early morning appointments [55] . Adherence varies among racial groups, but the contribution of provider bias to the existence and perception of nonadherence may be underappreciated. Pro-White implicit bias among providers is associated with the quality of patient interactions, treatment decisions, quality of care, treatment adherence and outcomes [56] [57] [58] . Patient mistrust of providers predicts lower adherence among Black men with HIV [59] . Perceived discrimination predicts lower adherence for Black patients with HTN, an association mediated partly by patient stress and depression [60] . Providers' implicit bias may contribute to patient nonadherence and helps determine which patients they presume to be nonadherent [61] [62] [63] . Physicians seeing patients after coronary angiography rated Black patients as less likely to follow medical advice or participate in cardiac rehabilitation, and were less likely to rate them as 'the kind of person I can see myself being friends with.' They were less likely to rate Black patients as intelligent or educated, even after controlling for reported education [64] . Black patients with DM seen in clinics of a large health system were roughly three times as likely as White patients to be labeled nonadherent, even when hemoglobin A1c was at goal [65 && ]. Every clinician in an era of 'copy forward' electronic records must understand the potential for labels such as 'nonadherent' or 'noncompliant' -whether accurate or not-to become fixed in patients' records and prejudice new providers.

Most studies of implicit bias testing among providers find that those with high levels of pro-White bias have greater difficulties with patient-provider communication [57] . Black cancer patients seen by providers with higher implicit bias had more difficulty remembering details of the interaction, lower confidence in prescribed treatments, and greater perceived difficulty in completing treatments [66] . The relevance of these findings to patients' medical adherence and engagement is clear.

Racism may contribute to depression and anxiety among African-Americans. Black adolescents exposed to increasing levels of perceived discrimination have higher ratings of depressive and anxious symptoms [67] . Emergency visits for depression and self-reported burden of poor mental health spike among African-Americans after local police killings [68] . Black people with mental illness may face barriers to care such as insurance, but discrimination may also intervene. When psychotherapists receive voicemail messages featuring actors portraying people seeking help for depression or anxiety, all with the same commercial insurance plan, 'Black' callers are less likely to receive an appointment or callback [69] . Bias may affect clinician ratings of Black mental illness. African-Americans are particularly likely to receive a diagnosis of schizophrenia, a disparity possibly mediated by interviewers' perception of Black patients as less honest about their symptoms and by difficulties in patient-clinician relationships [70, 71] .

Social support Studies of social support by race show mixed results. Data from the 1980s showed lower levels of instrumental and emotional support among African-Americans, for whom low instrumental support was associated with increased odds of HTN [72] . Nationally representative data show similar emotional and financial support for Black and White respondents, but Black respondents lacking both were likelier to have HTN [73] . Physicians in the postangiography study were more likely to rate Black patients as likely lacking social support, even after controlling for patients' self-reported social support [64] .

A landmark 1999 study revealed bias among physicians randomized to video vignettes of actors www.co-cardiology.com portraying patients with angina that differed only by race and sex. The physicians were less likely to refer Black and women actors for cardiac catheterization [74] . Building upon these methods, Breathett et al. conducted studies that randomized professionals involved in decision-making about advanced therapy allocation to standardized vignettes, showing that race figured prominently in thought processes about decision-making and that adherence and social history emerged as important factors in decisions about Black patients. Recurring themes included beliefs that Black patients were sicker and less likely to be adherent and that respondents might have difficulty forming rapport with Black patients. The White patient was more likely to be offered HT and the Black patient more likely to be offered LVAD. In a separate study, children were seen as particular liabilities for women -especially Black women, to whom respondents attached concerns about financial stability [ 

Underrepresentation of non-White subjects in clinical studies is persistent and leads to biased risk prediction. Risk factors derived from the Framingham Heart Study underperform in predicting cardiovascular events among non-White patients [77] . HF guidelines recommend ancillary use of risk scores like the Seattle Heart Failure Model (SHFM) for advanced therapy decision-making. But SHFM, validated in largely White cohorts [78] , underestimates risk for all patients but particularly for Black patients [79, 80] . One group added Black race to a BTT risk score for 1-year post-HT outcomes and published an online calculator. The score also included recipient age, BMI, recent infection, serum bilirubin, and dialysis [5] . The model showed mildly improved concordance compared to one without race [81] . It is important to acknowledge the association of race with outcomes, but the wisdom of incorporating race itself as a 'risk factor' into a score intended to guide clinical decision-making must be pointedly questioned. Many single-center and multicenter studies fail to reproduce these findings [82] . UNOS analyses that demonstrate racial disparities in post-HT survival generally fail to account formally for center differences. Black patients disproportionately receive HT at centers that perform poorly based on score (IMPACT) that also includes Black race [83, 84] . The BTT and IMPACT risk scores appeared in journals whose editorial boards had no Black editors at the time of publication [85, 86] , which is emblematic of diversity deficits throughout medicine -and in cardiology and HF specificallythat may facilitate inappropriate invocations of race and propagate racialized thinking. Even machine algorithms are vulnerable to the biases of their programmers. A prediction algorithm used by a large health system widely underperforms in predicting risk for Black patients, for whom risk is far higher than predicted [87] . It is possible to overcome these barriers but awareness and intention are required [88] .

Implicit bias has emerged as a target for improving equity and inclusion among clinical teams and for reducing healthcare disparities. Frequently cited research has suggested that neurobiological processes underlying biases consist of distinct components: implicit, explicit, and behavioral [89] . Implicit Association Test scores among healthcare providers are similar to the general population [58] . Brain regions implicated in implicit bias include the amygdala, dorsolateral prefrontal cortex, and fusiform gyrus [90] . In placebo-controlled studies, White volunteers treated with propranolol have reductions in implicit association scores and lower fusiform and thalamic activation when shown images of Black faces, implicating b-adrenergic pathways and potentially anxiety or fear mechanisms in mediating implicit cognition [91, 92] . But a multitude of interventions aimed at reducing implicit bias are inconsistently associated with any impact on bias and less so with stable and durable change, in a literature largely plagued by lowquality study designs [56, 93] . Credible evidence that implicit bias training or other bias-reduction and diversity practices reduce racial gaps in healthcare delivery and quality is nonexistent, as is a rigorous framework for generating such evidence [94] . Currently accepted practices for reducing the impacts of bias notably aim to change thinking, which is not easily or regularly measurable, as opposed to targeting quantifiable behavior such as individual providers' quality metrics.

Black and Latinx physicians each comprise roughly 5% of the HF physician workforce (Fig. 4) , figures that are unrepresentative of the HF patient population. For Black patients, the availability of Black physicians may be profound. Messaging from Black physicians increases African-Americans' knowledge and information-seeking about COVID-19 [95] . In racially concordant interactions, Black patients were more likely to give their physicians the highest rating for 'likelihood of recommending this care provider to others' than in discordant encounters [96 && ]. Black and Latinx patients are more likely than White patients to seek care from physicians of the same race or ethnicity. Black patients are more likely to rate Black physicians as 'excellent' overall and to report that their doctor treats them with respect, explains problems, listens, and is accessible. Black patients with Black physicians are more likely than those with physicians who are not Black to report receiving preventive care and all necessary care [97] . Black neonates who receive care from Black doctors have a substantially reduced mortality, an effect even more apparent in complicated cases [98 & ]. I suggest that diversity deficits on clinical and research teams contribute to fatal flaws that perpetuate bias and health disparities. In 2020, a respected cardiology journal, which at the time had one Black and Latinx editor each on a board or more than 40, published a 'white paper' expressing hostility to diversity efforts in cardiology [99, 100] . The journal retracted the paper under pressure, noting critical factual inaccuracies and blandly promising 'a path forward to eliminate deficiencies in the peer review process' [101] . Diversifying its staff would be an obvious first step. The journal has several social media editors, as do many other journals, but no social justice editor.

A thorough examination of barriers to HF health equity created by implicit and 'unconscious' bias must acknowledge a history of explicit and fully conscious bias -and outright racism -in American healthcare. African-American mistrust of the medical establishment rightfully follows a long history of mistreatment that includes medical and surgical experimentation on enslaved people, theft of Black bodies for dissection and forced sterilization of Black women. The Tuskegee Project that studied the natural history of syphilis by withholding treatment from infected Black men is only the most prominent example of the medical abuse of African-Americans. The early era of American heart transplantation recapitulates this history. In 1968, the Medical College of Virginia (MCV), with its own history of racist grave robbing, admitted a Black man named Bruce Tucker after a traumatic brain injury. Without the knowledge or consent of Mr. Tucker's family, surgeons placed his heart in the body of a White patientthe first heart transplant in the segregated American South. The funeral director informed Mr. Tucker's family that his heart and kidneys were missing [102] . An all-White jury exonerated MCV of wrongdoing. MCV's successor, Virginia Commonwealth University (VCU), acknowledges this episode as an unfortunate part of its legacy and pledges to have conversations, learn, accept criticism and contribute to healing. It has not pledged to redress this crime with the family and community it harmed. The disparities of the COVID-19 outbreak have sparked necessary discussion about the impacts of structural racism and systemic bias on healthcare access and outcomes [103] . VCU's response to its own racist history is emblematic of the gulf between medicine's well meaning promise of gradual change and the disruptive action needed to address the matter of Black lives-and save them.

Racial bias likely intervenes at multiple points and at various levels (provider, patient, institution, research) in the journey toward advanced HF therapy. Initial suggestions for mitigating bias (Table 1) build upon on work by Arriola addressing bias in kidney transplantation [104] . Building an equity culture will require emphasizing racism, not race, as an essential factor in disparities. Standardizing evaluation processes and reporting data to a central body, in addition to designing prospective multicenter investigations, would facilitate comprehensive and quantitative assessments of inequity in advanced therapy distribution. Psychosocial assessments must be culturally appropriate and should include details of patients'' trust in providers, Provider C-Acknowledge that we live in a race-conscious society C-Participate in interventions that raise awareness of the impact of bias on medical care R-Expand research on the role of bias in LVAD and HT settings P-Partner with community practices serving vulnerable populations to increase referral rates P-Financially incentivize dialysis facilities to decrease racial disparities in referral Patient visits advanced care center Internal C/R-Implement and test patient navigation to enhance completion of the evaluation process C-Educate patients about evaluation, with sensitivity to histories of medical abuse, healthcare inequalities, and medical mistrust among Black and other marginalized patient groups R-Assess patient perceptions of barriers to completing evaluation and collect data to understand characteristics of patients who are unable to complete evaluation Center conducts evaluation Institutional Provider C/R-Develop and test patient navigation to help patients complete the evaluation process C/R-Create dashboards of determinants and trends of patients' ability to proceed to candidacy C-Intensify efforts to recruit diverse trainees and practitioners P-Expand access to quality public health insurance P-Health centers invest in community-level interventions to address social determinants of health including safety, pollution, transportation, and housing and food security P/R-Professional societies such as HFSA, ACC and AHA should convene writing groups to summarize the literature, set research agendas and issue guidelines to address disparities in advanced therapy R-Conduct center-level and multicenter research on the potential disparate impact and fairness of medical and psychosocial items used in evaluation perceived discrimination and understanding of barriers to adherence. Professional societies such as the Heart Failure Society of America, the American College of Cardiology, the American Heart Association and the Association of Black Cardiologists should convene writing committees to review the best available literature, suggest research agendas, issue clinical guidelines and best practices, and develop metrics and targets for patient access and outcomes. The unprecedented speed of COVID-19 vaccine development should prompt restlessness about the pace of our progress against HF disparities, which is dangerously behind and damnably slow. The evidence vacuum for efficacy in reducing bias and promoting equity is intolerable. All who are dedicated to improving health equity and justice must demand more targeted research and funding, more provider diversity, and a serious focus on eliminating health disparities. Supplemental Data Information for Figures Figure 1 : Heart failure (HF) death data were obtained from the Centers for Disease Control (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) database (wonder.cdc.gov). Age was adjusted to the US 2000 standard population. Annual excess age-adjusted African-American HF death rate (Fig. 1A) is the difference between the age-adjusted death rate due to HF (ICD-10 150.0, 150.1 or 150.9) among Black people and the ageadjusted rate among the non-Black population. Annual crude excess Black HF deaths in each 10year age group (Fig. 1B) is the number of HF deaths among Black people in each age group minus the product of the crude non-Black HF death rate and the Black population in that age group. Figures 2 and 3 : Data are from the UNOS registry from 2000 through 2016. First-time heart-only recipients with BMI at listing <60 (to reduce the likelihood of miscoding) were selected (N ¼ 34,532). Figure 2 shows the contribution of age, race, BMI, sex, year of transplant, and presence of an LVAD or and RVAD prior to transplant to the hazard of graft failure or death. Figure 3 displays race-specific hazards of graft failure or death as a function of BMI at listing with adjustment for the remaining variables examined in Figure 2 . Confidence bands have been removed for visual clarity. Figure 4 : Data on HF physicians were obtained from the Centers for Medicare and Medicaid Services National Downloadable File (https://data.cms.gov/ provider-data/sites/default/files/resources/ de04109ea8ad84f5d82cf77674f8d76c_1604886408/ mj5m-pzi6.csv) and from the Heart Failure Society of America membership directory (https://members.hfsa.org/individual-directory). Race and sex were assigned based upon visual inspection of publicly available photographs, the typical sex suggested by the first name, the typical race or geographic origin suggested by the surname, the actual geographic origins for physicians born outside the US and/or personal knowledge of the physician's identity.

All analyses and all figures were created in R 4.0.1.

National differences in trends for heart failure hospitalizations by sex and race/ethnicity

Racial disparities and outcomes of left ventricular assist device implantation as a bridge to heart transplantation

Strategies of wait-listing for heart transplant vs durable mechanical circulatory support alone for patients with advanced heart failure

Racial disparities in patients bridged to heart transplantation with left ventricular assist devices

Risk stratification of patients with current generation continuous-flow left ventricular assist devices being bridged to heart transplantation

A fully magnetically levitated left ventricular assist device -final report

OPTN/SRTR 2018 annual data report: heart

An early investigation of outcomes with the new 2018 donor heart allocation system in the United States

Reassessing recipient mortality under the new heart allocation system: an updated UNOS registry analysis

Unintended' consequences of changes in heart transplant allocation policy: impact on practice patterns

International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update

Recommendations for the use of mechanical circulatory support: ambulatory and community patient care: a scientific statement from the American Heart Association

Retrovirus Epidemiology Donor S. ABO and Rh(D) phenotype frequencies of different racial/ethnic groups in the United States

Influence of race/ethnic differences in pretransplantation panel reactive antibody on outcomes in heart transplant recipients

Racial differences in the development of de-novo donor-specific antibodies and treated antibody-mediated rejection after heart transplantation

The impact of race on survival after heart transplantation: an analysis of more than 20,000 patients

Current evaluation to ols for advanced therapies biased Givens 0268-4705 Copyright ß 2021 The Author(s). Published by Wolters Kluwer Health

Impact of the new pulmonary hypertension definition on heart transplant outcomes: expanding the hemodynamic risk profile

The effects of race on peak oxygen consumption and survival in patients with systolic dysfunction

Comparison across races of peak oxygen consumption and heart failure survival score for selection for cardiac transplantation

Comparative cardiorespiratory fitness in children: racial disparity may begin early in childhood

Characterization of the blood pressure response during cycle ergometer cardiopulmonary exercise testing in black and white men: Data from the Fitness Registry and Importance of Exercise: A National Database (FRIEND)

Cardiorespiratory fitness and exercise training in African Americans

Black and White race differences in aerobic capacity, muscle fiber type, and their influence on metabolic processes

Hemoglobin, muscle oxidative capacity, and VO2max in African-American and Caucasian women

Prediction of severe cardiovascular events by VE/VCO2 slope versus peak VO2 in systolic heart failure: a meta-analysis of the published literature

Predictive value of cardiopulmonary exercise testing parameters in ambulatory advanced heart failure

Prognostic characteristics of cardiopulmonary exercise testing in caucasian and African American patients with heart failure

Impact of recipient body mass index on organ allocation and mortality in orthotopic heart transplantation

The effect of body mass index on survival following heart transplantation: do outcomes support consensus guidelines?

Outcomes associated with obesity in patients undergoing left ventricular assist device implantation: a systematic review and meta-analysis

Outcomes of obese patients bridged to heart transplantation with a left ventricular assist device

Durable left ventricular assist device implantation in extremely obese heart failure patients

Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old

Association of BMI with overall and cause-specific mortality: a population-based cohort study of 3.6 million adults in the UK

Racial/Ethnic disparities in the prevalence of diabetes and prediabetes by BMI: patient outcomes research to advance learning (PORTAL) Multisite Cohort of Adults in the US

Diabetes mellitus is not a risk factor for patients supported with left ventricular assist device

Implantation of left ventricular assist device results in immediate improvement of glucose metabolism in patients with and without diabetes mellitus

Metabolic dysfunction in continuousflow left ventricular assist devices patients and outcomes

Ethnic minority disparities in progression and mortality of predialysis chronic kidney disease: a systematic scoping review

Genetics and ESKD Disparities in African Americans

Race/ ethnicity and cardiovascular outcomes in adults with CKD: findings from the CRIC (Chronic Renal Insufficiency Cohort) and Hispanic CRIC Studies

Sex-and race-related differences in characteristics and outcomes of hospitalizations for heart failure with preserved ejection fraction

Characteristics and outcomes of patients undergoing combined organ transplantation (from the United Network for Organ Sharing)

Increased incidence of chronic kidney injury in African Americans following cardiac transplantation

Renal risk stratification in left ventricular assist device therapy

Prevalence of chronic kidney disease among black individuals in the US after removal of the black race coefficient from a glomerular filtration rate estimating equation

Kidney disease, race, and GFR estimation

The stanford integrated psychosocial assessment for transplantation: a prospective study of medical and psychosocial outcomes

Standardized use of the stanford integrated psychosocial assessment for transplantation in LVAD patients

Psychosocial assessment of candidates and risk classification of patients considered for durable mechanical circulatory support

Utility of the psychosocial assessment of candidates for transplantation in patients undergoing continuous-flow left ventricular assist device implantation

The value of Stanford integrated psychosocial assessment for transplantation (SIPAT) in prediction of clinical outcomes following left ventricular assist device (LVAD) implantation

Psychosocial evaluation in patients undergoing left ventricular assist device implantation using the transplant evaluation rating scale

Racial and ethnic disparities in medication adherence among privately insured patients in the United States

Discordance between 'actual' and 'scheduled' check-in times at a heart failure clinic

Implicit bias in healthcare professionals: a systematic review

A decade of studying implicit racial/ ethnic bias in healthcare providers using the implicit association test

Implicit racial/ethnic bias among healthcare professionals and its influence on healthcare outcomes: a systematic review

Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV

Perceived discrimination and medication adherence in black hypertensive patients: the role of stress and depression

Patient and provider assessments of adherence and the sources of disparities: evidence from diabetes care

Disparity in physician perception of patients' adherence to medications by obesity status

Factors influencing physicians' judgments of adherence and treatment decisions for patients with HIV disease

The effect of patient race and socio-economic status on physicians' perceptions of patients

Nonadherence labeling in primary care: bias by race and insurance type for adults with type 2 diabetes

The effects of oncologist implicit racial bias in racially discordant oncology interactions

Associations between trajectories of perceived racial discrimination and psychological symptoms among African American adolescents

Emergency department visits for depression following police killings of unarmed African Americans

Sorry, I'm Not Accepting New Patients': an audit study of access to mental healthcare

Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities?

Interviewer-perceived honesty as a mediator of racial disparities in the diagnosis of schizophrenia

Social support and hypertension among blacks and whites in a rural, southern community

Race/ethnicity and hypertension: the role of social support

The effect of race and sex on physicians' recommendations for cardiac catheterization

Doesrace influence decision making for advanced heart failure therapies?

:e2011044. The investigators used standardized vignettes of patients with advanced heart failure that differed only by race and sex. Respondents were particularly concerned about the Black woman's financial stability

Race/ethnic differences in the associations of the framingham risk factors with Carotid IMT and cardiovascular events

Left ventricular assist device patient selection: do risk scores help?

The Seattle Heart Failure Model: prediction of survival in heart failure

Utility of the Seattle Heart Failure Model in patients with advanced heart failure

Development of a transplantation risk index in patients with mechanical circulatory support: a decision support tool

A multiinstitutional outcome analysis of patients undergoing left ventricular assist device implantation stratified by sex and race

Racial disparities in outcomes of adult heart transplantation

Creation of a quantitative recipient risk index for mortality prediction after cardiac transplantation (IMPACT)

Dissecting racial bias in an algorithm used to manage the health of populations

A racially unbiased, machine learning approach to prediction of mortality: algorithm development study

Implicit social cognition: from measures to mechanisms

The neuroscience of race

Propranolol reduces implicit negative racial bias

beta-Adrenoceptor blockade modulates fusiform gyrus activity to black versus white faces

Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review

A call for grounding implicit bias training in clinical and translational frameworks

Comparison of knowledge and information-seeking behavior after general COVID-19 public health messages and messages tailored for black and latinx communities: a randomized controlled trial

Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings

Among more than 117,000 surveys, patient-physician race discordance was associated overall with significantly lower odds (OR 0.88) of the physician receiving the highest rating for 'likelihood of recommending this care provider to others

Patient-physician racial concordance and the perceived quality and use of healthcare

Physician-patient racial concordance and disparities in birthing mortality for newborns

The investigators examined 1.8 million Florida birth records from 1992 to 2015. The mortality rate for Black newborns was 2.7 times that for White babies, suggesting an annual excess of 2800 Black neonatal deaths in Florida alone. Under the care of Black physicians, mortality for Black neonates decreases by 58% in unadjusted analyses and by 39% in a fully specified model

Diversity, inclusion, and equity: evolution of race and ethnicity considerations for the cardiology workforce in the United States of America from 1969 to 2019

Retraction to: Diversity, Inclusion, and Equity: Evolution of Race and Ethnicity Considerations for the Cardiology Workforce in the United States of America From 1969 to 2019

The organ thieves: the shocking story of the first heart transplant in the segregated South

How structural racism works -racist policies as a root cause of U.S. Racial Health Inequities

Race, racism, and access to renal transplantation among African Americans

None.Financial support and sponsorship This work was supported by the Katz Cardiovascular Research Prize, Columbia University Irving Medical Center Division of Cardiology, Department of Medicine.

There are no conflicts of interest.