Racial and Ethnic Disparities in Cardiovascular Care

Heart disease is the leading cause of death in the United States. The risk of heart disease differs by demographic characteristics including race and ethnicity, socioeconomic status, sex, and geography. This editorial will highlight key points from a recently published narrative review on racial and ethnic perioperative healthcare disparities among patients undergoing cardiac surgery.1 Healthcare disparities are measurable differences among specific population groups that prevent the attainment of their full health potential. They include differences in the incidence, prevalence, burden of disease, and mortality.2 Although the term disparity is often used in reference to race and ethnicity, disparities exist across other dimensions including socioeconomic status (SES), gender, sexual orientation, and disability status. In addition to the human costs, healthcare disparities exert a financial burden on our society.3 To address disparities, it is important to examine between-group differences closely without bias, with the aim of understanding mechanisms and identifying actionable solutions. This editorial focuses on racial and ethnic disparities in care of the cardiovascular (CV) patient. We specifically examine evidence of healthcare disparities in cardiac surgery, summarize current evidence on factors contributing to racial and ethnic disparities, and propose actionable solutions, including ways that the individual can advance health equity. Non-Hispanic Black persons have the highest age-adjusted risk of death from heart disease.4 Healthcare disparities result from medical and non-medical factors. Black and Hispanic patients have the highest burden of hypertension, diabetes, obesity, and coronary artery disease (CAD).5 Additionally, factors lumped under the category of social determinants of health (SDoH) – nonmedical factors that influence health outcomes- conditions in which people are born into, grow, work, live and age - disproportionally affect Black and Hispanic patients.6 SDoH can be traced back to discriminatory practices such as neighborhood redlining and systematic and structural racism, which have resulted in higher area deprivation, less access to healthy food, and lower education levels in neighborhoods where Black and Hispanic patients reside.7 Unconscious or implicit bias also plays a role. Discrimination has also been shown to have physiological responses; it is associated with higher levels of oxidative stress, tissue inflammation, higher allostatic loads, and telomere shortening, factors that contribute to earlier development of disease and premature aging.8 Despite improvements in surgical techniques leading to a population-level decline in coronary artery bypass grafting (CABG) mortality over the last 3 decades, a 2019 meta-analysis of comparative studies found that after adjusting for confounders, Black patients are 24% more likely than White patients to suffer post-CABG mortality.9 Contributing factors likely include differences in quality of care such as lower frequency of internal mammary artery use in Black patients and higher rates of transfusion of allogenic red blood cells.10, 11 The incidence and prevalence of heart failure (HF) is higher among Black individuals compared with other ethnic groups.5 When stratified by age groups, the prevalence of heart failure is higher among young and middle-aged Black adults compared to young and middle-aged White adults. This has financial and economic implications as it increases disability rates in the workforce for these populations. Additionally, although the overall prevalence of heart failure has remained stable, the incidence of HF is increasing among non-Hispanic Black and Mexican American individuals.12 Though disproportionately affected by heart failure, Black and Hispanic patients have been shown to be on average sicker than non-Hispanic White (NHW) patients at the time of referral for advanced heart failure therapies and experience a higher morbidity burden after left ventricular assist device (LVAD) implantation.13, 14 Given the increased burden of outpatient care associated with LVADs, SDoH becomes particularly crucial to examine and be aware of in racial and ethnic minority populations. Additionally, Black patients have lower rates of heart transplantation compared to White patients, and higher rates of waitlist mortality.15 Valvular heart disease (VHD) is underdiagnosed in UREM populations.16 Additionally, once diagnosed, UREM patients may be less likely to undergo surgical repair of VHD.16, 17 In a single high-volume hospital, Yeung et al found that Black patients underwent surgical aortic valve replacement less often than White patients (39% vs 53%; p = 0.02);18 Alqahtani et al, had similar results (6.7% vs 11.3%; p < 0.001).19 Similarly racial and ethnic disparities have been shown in the utilization of transcatheter aortic valve repair (TAVR).20 Data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS TVT) registry revealed that from 2012 to 2014, Black patients were underrepresented in TAVR cases compared to White patients (3.8% vs 93.8%).21 Unequal access to quality healthcare significantly hinders the achievement of equitable perioperative outcomes. Black and Hispanic patient populations exhibit higher rates of being uninsured or underinsured which compromises access to quality and continuous care, increasing the likelihood of advanced disease at presentation, and high utilization rates of emergency care.22 Lack of insurance leads to delay in diagnosis and access to effective therapies. While the Affordable Care Act expanded health insurance coverage, people of color still represent approximately 60% of the uninsured population.1 Additionally, hospitals that serve predominantly Black and Hispanic patients tend to be under-resourced (i.e., safety-net hospitals).1, 23 While the Hospital Readmission Reduction Program, a value-based care strategy that incentivizes quality improvement through financial penalties on hospitals, is promising, recent studies suggest it disproportionately penalizes safety-net hospitals, which tend to serve a higher proportion of under-represented racial and ethnic minorities (UREM) and socioeconomically disadvantaged patients.24 Referral patterns of primary care physicians (PCPs) have also been implicated in poor CV outcomes; PCPs who serve predominantly UREM patients tend to have a smaller specialist network.23 Using Medicare claims data from 2009-2010, Landon et al showed that the mean number of specialists with whom a primary care physician shares patients was lower for Black patients than for White patients, compromising access to high quality care.25 When referred for cardiac surgery, Black and Hispanic patients are more likely to be referred to surgeons with higher risk-adjusted mortality and low-volume hospitals, compared with NHW patients.26 Similar trends are found in minimally invasive structural heart disease interventions.27 Implicit bias persists in everyday decision-making and has been shown to be more pervasive in unconscious decision making.28 Studies suggest physician decision-making might be influenced by stereotypes regarding UREM patients' health behaviors and socioeconomic background.29 This may influence the decision to refer for specific therapies or specialty care. Using Medicare administrative claims data from 2008–2014, Cascino et al showed that Black patients with heart failure were 3% less likely to receive an LVAD than White beneficiaries.30 This disparity persisted even after adjusting for individual poverty and neighborhood deprivation index. In 2024, Rose et al showed, using a 19-state inpatient discharge database (2010 – 2018) that among patients with heart failure reduced ejection fraction (HFrEF) the combined rates of LVAD implantation and heart transplant were lower for Black men compared with White men and lower for women compared to men.31 Similarly, Rodriguez et al showed that in a large health system comprised of 4 community hospitals, Black patients were less likely to be referred to cardiothoracic surgery for treatment of aortic valve disease even after adjusting for clinical and echocardiographic variables.32 There is significant evidence showing that cardiac rehabilitation (CR) improves outcomes following CV procedures. Using the National Cardiovascular Data Registry between 2009 and 2012, Aragam et al showed that Black and Hispanic patients with CAD were less likely to be referred to CR after percutaneous coronary interventions.33 Risk Aversion. Public availability of outcomes data has led to increased risk aversion among clinicians, limiting access to surgery and interventional procedures for patients deemed high risk, even though they may derive benefit.34 Risk aversion may disproportionally affect racial and ethnic minority patients as they tend to present with advanced disease at diagnosis. Notably, despite lacking biological justification, race-based factors still persist in cardiac surgery risk models, e.g. STS risk score.35 Recently, medical risk models have been under scrutiny for the inclusion of race and race-derived factors in the computation of risk. Race and race-derived factors have been removed from many medical risk models, due to recognition that observed outcomes stem from social determinants of health and systemic racism, not race itself.36 Patient-related factors contribute substantially to disparities in equitable CV care. These factors encompass personal health behaviors, comorbidities, health literacy, and willingness to undergo procedures.1 Several elements influence patient hesitancy or refusal to undergo needed CV procedures, including distrust in the healthcare system, financial burden, inadequate patient-clinician relationships, cultural beliefs, and understanding of surgical procedures. Studies demonstrate that Black individuals are more likely to decline invasive diagnostic and surgical procedures compared to White patients.37, 38 Distrust and skepticism in the healthcare and medical professionals is deep-rooted and supported by unethical and inappropriate experimentation on Black patients and systemic racism. These experiences carry forward in contemporary medical mistrust although is improved by patient-clinician race concordance.1 Health literacy also plays a crucial role. UREM often exhibit lower health literacy rates, potentially due to limited access to education and healthcare, further hindering effective communication with clinicians.39 These concerns further highlight that having a higher level of health literacy would likely allow patients to actively participate more in their care and have a better idea of their disease process. Financial toxicity- the conflict between affording healthcare and basic necessities- discourages necessary procedures. This burden is more prevalent in UREM and socioeconomically disadvantaged populations.40 Often compounding expenses is delayed disease presentation which often necessitates more complex or time-sensitive surgeries, exacerbating financial strain. Healthcare disparities create an oversized human and financial burden and must be addressed urgently as the U.S. population ages. Steps that mitigate challenges at each level must be taken:1.Research and Data Strategies. Pursue understanding of observed healthcare disparities: Attributing poor outcomes to race is dangerous as it assumes that those outcomes are not modifiable. Rather, poor outcomes may cluster in certain ethnic groups who have higher exposure to other covariates including living in areas of higher deprivation, lower health literacy, etc.31, 322.Health Policy and System Level Strategies: Improve Healthcare Access: Improve referral networks, provide resources for safety-net hospitals.3.Health System Strategies: Social Determinants of Health Scoring tools such as the Distressed Communities Index (DCI) can identify patients at risk of financial toxicity. Notably, Black patients demonstrate higher DCI scores, potentially linking financial hardship to increased disease burden, illness severity, poorer outcomes, and racial disparities.41 Knowledge of these barriers can be leveraged to connect patients with resources, for example transportation to medical appointments, low cost prescription programs, and health literacy programs.4.Clinician-Focused Strategies: Increase diversity of healthcare professionals: Interestingly, research suggests improved communication when providers and patients share similar characteristics.42 Racial concordance is linked to increased understanding and uptake of procedures like CABG and invasive CV screening among Black patients.42 One study estimated that diversifying the physician workforce could significantly reduce Black-White disparities in CV mortality by 19% by increasing preventive service utilization.435.Address Implicit Biases: Implicit bias is pervasive and may be harmful, and addressing it is challenging. Studies show that many implicit bias training programs may not be effective. For implicit bias training to produce intended outcomes, the training should increase awareness and self-motivation, and provide evidence-based strategies that decrease its influence of clinical decision-making.44 Other strategies that may mitigate implicit biases include standardization of clinical protocols and mandatory decision support tools.45 Healthcare disparities impact every aspect of cardiovascular care. Cardiac anesthesiologists in conjunction with cardiac surgeons, cardiologists, and intensivists can help mitigate these disparities through the actionable steps described above and elsewhere.46 Without intentional efforts to address healthcare disparities, segments of the populations will continue to experience higher rates of morbidity and mortality. While this article focused on disparities by race and ethnicity, the barriers, and solutions for other populations (e.g., sexual and gender minorities, low socioeconomic status, rural populations) will be similar.