Trial leadership by women is associated with racial diversity among heart failure clinical trial participants: a systematic bibliometric review 2000–2020

Background

For the results of randomized controlled trials (RCTs) to be generalizable, they should report on and include the broad range of patients who have the disease.

Purpose

We assessed temporal trends and trial factors associated with 1) the reporting of race or ethnicity data and 2) the enrolment of Black, Indigenous, and people of colour (BIPOC) in Heart Failure (HF) RCTs.

Methods

We searched MEDLINE, EMBASE, and CINAHL for RCTs that recruited adults with HF and were published in journals with an impact factor ≥10 between January 1, 2000 and June 17, 2020. We extracted data in duplicate and used the Cochran-Armitage and Jonchkeere-Terpstra tests to examine temporal trends. We used multivariable regression to assess the independent association between trial factors and the outcomes of interest.

Results

A total of 414 RCTs met inclusion criteria, of which a vast majority (90.6%; 95% CI 87.4–93.2%) were coordinated in either Europe or North America. Only 157 of the 414 RCTs (37.9%; 95% CI 33.2–42.8%) reported race/ethnicity data; among the 158,200 participants in these trials, only 29,512 (18.7%; 95% CI 18.5–18.9%) were BIPOC. There was a significant increase in the reporting of race or ethnicity data (from 26.9% in 2000–2001 to 54.2% in 2019–2020, p<0.001) and in enrollment of BIPOC (from 16.5% in 2000–2001 to 23.9% in 2019–2020, p=0.038) between 2000–2020. Trial leadership by a woman was associated with twice the adjusted odds of reporting of race or ethnicity data (OR 2.0; 95% CI 1.1–3.8; p=0.028) and an 8.4% (95% CI 1.9–15.0%; p=0.012) adjusted increase in enrollment of BIPOC. The race/ethnicity of trial leaders was not available for analysis.

Conclusions

Among HF RCTs published between 2000–2020, <38% reported data on race or ethnicity, although this increased over time. Among trials reporting such data, <19% of participants were BIPOC, with modest increases in enrollment over time. Trials led by women had greater adjusted odds of reporting race/ethnicity data and enrollment of BIPOC.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR

The Association Between Socioeconomic Status, Sex, Race / Ethnicity and In-Hospital Mortality Among Patients Hospitalized for Heart Failure

BACKGROUND

The association between socioeconomic status (SES), sex, race / ethnicity and outcomes during hospitalization for heart failure (HF) has not previously been investigated.

METHODS AND RESULTS

We analyzed HF hospitalizations in the United States National Inpatient Sample between 2015 and 2017. Using a hierarchical, multivariable Poisson regression model to adjust for hospital- and patient-level factors, we assessed the association between SES, sex, and race / ethnicity and all-cause in-hospital mortality. We estimated the direct costs (USD) across SES groups. Among 4,287,478 HF hospitalizations, 40.8% were in high SES, 48.7% in female, and 70.0% in White patients. Relative to these comparators, low SES (homelessness or lowest quartile of median neighborhood income) (relative risk [RR] 1.02, 95% confidence interval [CI] 1.00-1.05) and male sex (RR 1.09, 95% CI 1.07-1.11) were associated with increased risk, whereas Black (RR 0.79, 95% CI 0.76-0.81) and Hispanic (RR 0.90, 95% CI 0.86-0.93) race / ethnicity were associated with a decreased risk of in-hospital mortality (5.1% of all hospitalizations). There were significant interactions between race / ethnicity and both, SES (P < .01) and sex (P = .04), such that racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients. The median direct cost of admission was lower in low vs high SES groups ($9324.60 vs $10,940.40), female vs male patients ($9866.60 vs $10,217.10), and Black vs White patients ($9077.20 vs $10,019.80). The median costs increased with SES in all demographic groups primarily related to greater procedural utilization.

CONCLUSIONS

SES, sex, and race / ethnicity were independently associated with in-hospital mortality during HF hospitalization, highlighting possible care disparities. Racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients.

Abstract 14: Secular Trends in Racial and Socioeconomic Status Disparities in the Rate of Coronary Revascularization Among Post-Menopausal Women Before and After 2005 for Acute Coronary Syndrome: The Women Health Initiative

Background: We looked at a large multi-racial, geographically diverse cohort of post-menopausal women to determine whether revascularization for either acute coronary syndrome (ACS) or coronary disease (CHD) differed by race and socioeconomic status when 2002 ACC/AHA guidelines secular trends are considered.

Methods: Using data from the WHI, we evaluated the rate of revascularization among 20,262 post-menopausal women (2,181 were Black, 572 Hispanic, and 17,509 white). We chose 2005 as the cut-point for the secular trend as it usually takes 2-3 years for guidelines to be implemented. We used a Cox proportional hazards models with unadjusted, age-adjusted, and fully adjusted hazards ratios to examine revascularization disparities by race and SES.

Results: Revascularization rates increased over the two decades studied but the racial disparities did not narrow. Black women with either ACS or CHD had significantly lower rates of revascularization pre and post 2005. Hispanic women with acute coronary syndrome or CHD had significantly lower rates of revascularization pre-2005 and a trend for lower rates post-2005. Black women with STEMI had trend towards lower rates of revascularization pre and post 2005 compared to their white counterparts. Hispanic women with STEMI have similar rates of revascularization pre-2005 and a trend towards lower rates of revascularization post-2005. Black women with NSTEMI trend towards a higher rate of revascularization pre-2005 and a trend towards a lower rate of revascularization post-2005. Hispanics with NSTEMI had a trend for higher revascularization pre-2005, and similar rates of revascularization post-2005. Low SES women with acute coronary syndrome or coronary heart disease had no difference in the rate of revascularization pre-2005 and significantly lower revascularization post-2005. Low SES with STEMI and NSTEMI had comparable rates of revascularization for both time periods when compared to their high SES counterparts.

Conclusions: Black women with ACS or CHD had lower rates of revascularization, regardless of timing, compared to their white counterpart. Despite having similar rates of coronary events, low SES women had lower rates of revascularization in the post 2005 period when compared to their high SES counterpart.