Disparities in Utilization of Advanced Structural Heart Cardiovascular Therapies (2024)

PMCID: PMC11308080

Andrew M. Goldsweig, MD, MS,^a Megan Coylewright, MD, MPH,^b,∗ Ramesh Daggubati, MD,^c James B. Hermiller, MD,^d Howard C. Herrmann, MD,^e Aaron Horne, MD, MBA, MHS,^f Mazen Khalil, MD,^g Binita Shah, MD, MS,^h Triston B.B.J. Smith, MD,ⁱ Molly Szerlip, MD,^j SCAI 2022 Think Tank Structural Consortium, Terri Buehler,^k Jenny Cotton,^k Joe Evans,^l Jason Rudy,^m and Timothy M. Stivlandⁿ

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Disease education

To improve awareness, there is an opportunity for innovation in how and where information about SHD therapies is distributed. As examples, professional societies and several industry partners have supported community-based cardiovascular health education initiatives and ongoing projects partner industry sponsors with hospital systems to leverage alerts with the electronic medical record to change referral behavior. Building on the success of its “Seconds Count” campaign, SCAI is well positioned to disseminate information about SHD to its broad membership using a multiplicity of tools, including encouraging the implementation of successful initiatives. Prior large-scale initiatives to raise awareness of SH therapies have not yet demonstrated an impact on referral patterns for underserved populations, and further research is needed to identify best practices. Successful strategies in 1 procedural area (eg, valvular heart disease) can be replicated in other areas (eg, left atrial appendage occlusion). Importantly, patient and practicing clinician engagement is needed to utilize local experts to guide initiatives that are a best fit for each community.

Procedure and diversity, equity, and inclusion education

SCAI and industry partners may sponsor and facilitate peer-to-peer training in an exchange program between expert interventional cardiologists: high-volume SH proceduralists share skillsets to safely perform focused SHD interventions, and expert interventional cardiologists with diversity, equity, and inclusion training and experience raise awareness at large institutions to best practices in addressing systemic biases. It was acknowledged that awareness is not only needed in smaller hospitals regarding SHD therapies but also in high-volume SH programs that have the opportunity to reach a more diverse patient population. SCAI, in partnership with the industry, can combine expertise in direct-to-consumer advertising and through clinician education to ensure that existing health care disparities data in SHD is made transparent.

Trust

Centers of SHD care are not uniformly distributed geographically, instead clustering in large cities in academic medical centers often serving affluent populations, resulting in geographic disparities in care. For example, underrepresented racial and ethnic groups may seek care at smaller, community-based hospitals without SHD therapies because of long-standing relationships with familiar clinicians, rather than large academic centers, meaning that geographic disparities may not equate to actual distance traveled. It is well documented that African American patients have a demonstrated loss of trust in academic medical centers and researchers because of unethical trials focused on communities of color in the past, further impacting access to hospitals with SHD therapies.3^,4 Importantly, there are also striking sex and racial disparities in the SH workforce: women, African American and Latino physicians are markedly underrepresented as SH operators. Racial and cultural discordance between health care providers and patients results in barriers in communication and relationship building.5

Clinical trials of SH therapies

New devices and cutting-edge trials in SH are offered to large hospitals and academic centers, with invited investigators made up almost exclusively of men from overrepresented racial groups; this is then reflected in the SH workforce and the patient population included in trials.

Barriers to performing clinical trials at community-based hospitals and seeking out diverse principal investigators include a lack of research infrastructure, including funding for the research staff and support for physician investigators; concerns about the quality of data collection; and valuing speed of study start up and enrollment over other factors. An informal network and process of selecting investigators and institutions, dependent upon reputation, has perpetuated a lack of diverse investigators. Strategies to increase diversity in research leaders and community hospital participation in SHD clinical trials should be explored and may include the provision of increased resources to underrepresented sites, including resources for patients who are underinsured or uninsured (eg, copay reimbursem*nt), as well as novel trial design considerations (eg, prespecified enrollment criteria in the United States by race and ethnicity) and statistical analysis incorporating varying quality of data. Social and demographic concordance may be particularly important in clinical research, and it is well documented that more women in clinical trial leadership leads to greater diversity among patients.6

The panel proposed several strategies to improve access to SH therapies:

• 1.

  To overcome barriers to access of specific hospitals, either due to travel distance or perceived trust, SCAI can facilitate initiatives to address patient populations currently lacking SH care. In particular, the group explored the potential of SCAI and industry aiding in the development of care networks with funding to create systems to facilitate travel to regional centers.

• 2.

  Industry partners and SCAI alike were encouraged to commit to clinical and training support to smaller SH programs in hospitals serving underserved populations, shifting the focus to access and quality measures over volume, with SCAI facilitating peer-to-peer mentoring.

• 3.

  An emphasis on initiatives that seek to diversify the SHD workforce as well as industry employees was made. Both SCAI and industry have the ability to impact the underrepresentation and lack of visibility of women and Underrepresented in Medicine physicians through deliberate initiatives to increase involvement and leadership at scientific sessions, as site principal investigators in research studies, and as coinvestigators and coauthors in clinical trials.

Ultimately, it is inadequate for SH teams to simply wait for patients to be referred and travel to them—using the same process for each patient; without a change in systems of care, we are unlikely to succeed at reducing disparities. Instead, to provide appropriate care to a diverse society, clinicians and industry partners must be flexible to meet different communities where they are—geographically, educationally, and demographically.

Table1

Recommendations for SCAI and industry partners to address health care disparities in SHD care and the SHD workforce.

Declaration of competing interest

Andrew Goldsweig, Megan Coylewright, Ramesh Daggubati, James Hermiller, Howard Herrmann, Aaron Horne, Mazen Khalil, Binita Shah, Triston Smith, and Molly Szerlip reported no financial interests. Terri Buehler and Jenny Cotton are employees at Medtronic. Joe Evans is an employee at LiveNova. Jason Rudy is an employee at Philips Healthcare. Timothy Stivland is an employee at Boston Scientific.

Funding sources

This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics statement

This manuscript has adhered to the relevant ethical guidelines.