Table 2:

Seeking Equity- HFrEF Data by Race and Gender

	Reasons for Disparities	Strategies for Equity
Exercise training (cardiac rehabilitation)
Race/Ethnicity and Gender	Patient level factors older age (62–83 years), low socioeconomic position, limited access (underinsurance, prohibitive co-pays, and proximity to rehab center), greater comorbidity burden (COPD, CVA, CKD, cognitive dysfunction), and race, ethnicity and female sex are associated with less participation in exercise training [72, 73].	System-wide interventions to broaden insurance coverage and decrease copays. Expansion of exercise training services to include community, home- and internet-based cardiac rehabilitation. Government programs aimed at improving residential environments to enhance green space and facilities for physical activity to promote exercise outside of formal rehab centers.
	Language barriers and low health literacy [59].	Hospital support to widen use of interpreter services including video/audio services. Ongoing screening measures to identify communication barriers e.g., low health literacy and implementation of timely targeted interventions. Patient education to improve awareness on the importance of exercise training may result in improved adherence.
	Physician perceptions of patient interest and ability to tolerate exercise training (association of patient referral and physician presumed patient frailty) [32].	Physician education and awareness programs to address biases and gaps in disease management including referrals for exercise training and mental health support especially for women. Shared decision-making.
	Gender biases contribute to less disease management program referrals including exercise and mental health [10].	Mandatory gender bias mitigation training; mandatory and automated referrals for hospitalized HFrEF patients at discharge.
	Lack of and/or inadequate social support (e.g., larger proportion of older women live alone) [85].	Enhance home health care for patients of color and women with HF Leverage use of information technology
Device therapy: Cardiac Resynchronization Therapy (CRT) and Mitraclip
Race/Ethnicity and Gender	Underrepresentation of racial/ethnic patients of color and women in HF clinical trials [67].	Make clinical trials more inclusive for better understanding of HF and to ensure generalizability of trial outcomes to underrepresented HFrEF populations via extension of NIH policy mandating inclusion of racial/ethnic patients of color and women to industry sponsored HF clinical trials. Prioritize areas with a high proportion of patients of color and women during clinical trial site selection [67]. Racial/ethnic and gender diversification of investigators to allay participate mistrust. Education, awareness campaigns, and local community leadership involvement to allay research mistrust and improve recruitment Incentivize clinical trial participation (e.g., compensation for time, transportation, etc.).
	Underinsurance [59] and limited access to specialist care.	Broaden insurance coverage and reduce copays for HF therapies. Advocacy and resource allocation to address limitation in access related to unequal geographical distribution of cardiologist workforce. Leverage use of information systems technology including telemedicine.
	Lack of social support (intertwined with low socioeconomic position and neighborhood deprivation) [59].	Expand home-based care for patients of color and women with HF. Leverage use of information technologies to improve social support.
	Racial, ethnic, and gender biases [63, 64].	Mandatory evidence-based clinician training on bias reduction and anti-racism therapy.
	Patient mistrust of health system (related to racial, ethnic, and gender biases) contributes to avoidance and refusal of HF therapy [66].	Patient education and advocacy. Loan forgiveness programs and medical grants/scholarships to recruit more racial/ethnic people of color and women physicians to improve patient-physician racial/ethnic and gender concordance.
VAD/Transplant
Race/Ethnicity, and Gender	Racial biases [63, 64] and structural racism.	Funding to support evidence-based Implicit racial/gender bias reduction and structural racism policy changes. Implementation research to test strategies that reduce bias and structural racism. Hospital funding support.
	Biologic factors such as genes likely responsible for increased immunosuppressant metabolism (CYP3A5*1 – associated with higher clearance and lower bioavailability of tacrolimus in African Americans) and immune and inflammatory dysregulation (partially explains higher odds of allograft failure and lower post heart transplant survival among African Americans) [69]. African Americans are most likely to receive HLA-mismatched and race-mismatched grafts, but this accounts for only a small portion of racial disparity in outcomes [69].	Funding of genetic/molecular studies to understand the role of genetics, including immunologic factors in graft failure and heart transplant survival in high-risk racial/ethnic populations of color (African Americans and Hispanics) to individualize immunosuppressive regimens [68, 86]. Recognition and incorporation of pharmacogenetics in post heart transplant immunosuppressive algorithms. Mandating and implementing uniform guidelines across transplant centers.
	Underinsurance [74] (African Americans and Hispanics are disproportionately uninsured [87])	Broaden health care insurance coverage for racial/ethnic groups of color including coverage for immunosuppressive regimens and heart transplant care.
	Listing in low volume transplant centers, particularly Hispanics [88], and transplantation at transplant centers with higher-than-expected mortality [77].	Financial and other resource support for improved transplant center performance. Incentivizing outcomes to improve quality of care in worse performing transplant centers.
	Low socioeconomic position, limited access to care and being a patient of color are associated with low likelihood of heart transplantation, death, retransplant, higher risk of transplant rejection and loss, and other adverse post heart transplant outcomes (poorer adherence, hospitalization, and infection) [77, 86, 89].	Broadening insurance coverage for heart transplant recipients including coverage for immunosuppressive regimens and heart transplant care. Strengthening existing transplant counselling and education programs to offset nonadherence resulting from financial strain and low health literacy. Early referral for transplant listing.
	Social support and marital status [90].	Strengthen home and community-based care for high-risk patients of color and women with HF. Leverage technology to improve social support.
	VAD implantation refusal by women [91].	Offer patient education to improve awareness on the benefits of advanced HF therapies.

HFrEF indicates heart failure with reduced ejection fraction; VAD, ventricular assist device; COPD, Chronic pulmonary lung disease; CVA, Cerebrovascular disease; CKD, Chronic kidney disease; NIH, National Institutes of Health.