BackgroundRace influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies.Methods and ResultsMembers of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation.ConclusionsBlack race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

IMPORTANCE Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. OBJECTIVE To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. DESIGN, SETTING, AND PARTICIPANTS In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. EXPOSURE Randomization to clinical vignettes. MAIN OUTCOMES AND MEASURES Thematic differences in allocation of advanced therapies by patient race and gender. RESULTS Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. (continued) Key Points Question Is bias against a patient's gender and race associated with the allocation of advanced heart failure therapies? Findings In a qualitative study of 46 health care professionals, there was more bias against women compared with men when evaluating appearance and social support, particularly among African American women. Fina...

Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) are clinically and molecularly heterogeneous clonal myeloid disorders with a poor prognosis especially in the relapsed refractory setting and in patients above the age of 60. While allogeneic hematopoietic stem cell transplantation (ASCT) is a potentially curative approach, high relapse, morbidity, and mortality rates necessitate the development of alternative therapies. Immune checkpoint inhibitors unmask tumoral immune tolerance and have demonstrated efficacy in the treatment of chemotherapy-resistant hematologic and solid malignancies. The rationale for the investigation of those agents in AML and MDS is supported by an observed increased expression of programmed cell death 1 protein (PD-1) and ligand 1 (PD-L1) in the hematopoietic microenvironment of AML and MDS, and its association with low TP53 and a poor prognosis. Early clinical experience in combination with a hypomethylating agent has shown encouraging responses; however, larger clinical trials are needed to determine the role of checkpoint inhibition in myeloid malignancies.

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Research Objective Racial bias influences allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices (VAD). It is unknown whether sex and racial biases influence the allocation of advanced therapies among women. The objective is to determine whether the intersection of patient sex and race influences clinicians' decision making during the allocation of advanced heart failure therapies. Study Design Participants were randomized to clinical vignettes which varied by patient race (23 African American, 23 White) and sex (40 women, 6 men), with purposeful target of women vignettes in order to compare with prior studies. Participants were interviewed about their decision making process using the think‐aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with t tests. Population Studied U.S. members of an international heart transplant organization. Principal Findings Allocation differences centered upon five themes. First, clinicians’ critiqued the appearance of the women more harshly than men as overall impressions. Second, the African American man was perceived as sicker than other racial/sex groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared to the White woman. Fourth, there were greater concerns about adequacy of social support of the women. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were greater concerns for the African American woman. Spouses were deemed inadequate support for women. Last, participants recommended VAD over transplant for all racial/sex groups. Surveys demonstrated similar final recommendations. Conclusions Despite identical clinical vignettes, the decision making process varied by patient sex and race. Women patients were judged more harshly by their appearance and adequacy of social support, particularly the African American woman. Implications for Policy or Practice Future research should investigate whether objective assessments of social support lead to equity in advanced therapy allocation. Primary Funding Source National Institutes of Health.