Introduction
Use of heart transplant (HT) and left ventricular assist device (LVAD) are considered
standard of care for eligible patients with end-stage heart failure (HF). In assessing
eligibility, caregiver assistance is an important consideration in a patient's candidacy.
While studies have shown that individuals without caregivers have worse survival outcomes,
few studies have demonstrated how caregiver relationships differ based on sex and
race, and whether that impacts eligibility for HT/LVAD.
Hypothesis
Women and Black patients are less likely than men and non-Black patients, respectively,
to have a spouse listed as primary support, which may adversely affect eligibility
for HT/LVAD.
Methods
We identified all patients (N=534) evaluated at Emory University for HT/LVAD from
2011 to 2016. Stanford Integrated Psychological Assessment for Transplant (SIPAT)
scores were compared by sex and race using Wilcoxon rank-sum tests. The outcome of
HT/LVAD evaluation according to primary caregiver relationship was compared by sex
and race using X2 analysis. Multivariable logistic regression was used to determine the association
between primary caregiver and HT/LVAD eligibility according to sex and race, adjusted
for age, HF etiology, insurance, inotrope dependence, bilirubin, albumin, allosensitization,
CKD stage, and SIPAT score.
Results
The mean age of the cohort was 52 ± 13 years; 171 (32%) were women and 294 (55%) were
black. Total SIPAT scores did not vary significantly between men and women or blacks
and non-blacks, regardless of primary support person. Women were less likely to have
a spouse as primary support, and were more likely to have a parent or child as primary
support (Table). Black patients were less likely to have a spouse as primary support,
and were more likely to have a parent as primary support. In sex-stratified multivariable
models, the choice of primary caregiver did not affect eligibility for HT/LVAD for
women (P=0.8) or men (P=0.4). In race-stratified multivariable models, blacks with
a parent as primary caregiver were less likely to be eligible for HT/LVAD (OR=0.17,
95% CI 0.03 - 0.97, P=0.04), however the primary caregiver was not associated with
eligibility for HT/LVAD in non-black patients (P=0.9).
Conclusion
The choice of primary support person has a modest effect on decreasing eligibility
for black patients being evaluated for advanced HF therapies, but not for women. More
research is needed to determine unique barriers to advanced HF therapies for female
and black patients.
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Identification
Copyright
© 2020 Published by Elsevier Inc.
