A Call to Action Toward Equity in Heart Failure: Implementation Science as Tool for Change

Health equity is achieved when every person, regardless of age, sex, race, socioeconomic status, neighborhood or otherwise, has an opportunity to achieve their optimal health. There are many challenges to achieving health equity, particularly for patients with heart failure. Heart failure is unique because we have in our armamentarium a wealth of treatment options (whether pharmaceutical, interventional, or device related) that can reduce morbidity and mortality and improve quality of life for patients. Unfortunately, there is a major gap in terms of ensuring that all patients who may benefit from these therapies can access them. Research has shown that there remain significant disparities across the spectrum of heart failure in components like incidence, treatment including the optimization of guideline directed medical therapy (GDMT), device utilization, access to advanced heart failure therapies like left ventricular assist device and heart transplantation, and, importantly, mortality. As a medical and scientific community, we cannot allow these disparities to persist. With such overwhelming evidence of disparities across many domains of the disease course in heart failure, how can we begin to make headway?

The American Heart Association (AHA) Scientific Statement by Breathett et al. helps us begin to answer this question through the lens of implementation science. As the authors explain, implementation science is the method through which evidence-based medicine is translated to both policy and practice. Implementation science through a health equity lens takes into consideration structural factors like racism, bias, and socioeconomic status and builds a strategy to tackle health disparities recognizing the power of these social forces. It is not enough to identify a new medication, for example, that acts on a novel pathway to interrupt the endless cycle of heart failure readmissions. If we cannot get that medication effectively into the hands of those who need it most – those who may be most burdened by heart failure hospitalizations and death – then we have missed a critical step, and we could be indeed furthering health inequities.

Effective use of implementation science relies on a framework. As Breathett and colleagues illustrate, there are many potential frameworks that can be employed, some focusing on implementation, others on dissemination, and many on both. Central themes that emerge in many of the frameworks, and that are particularly necessary in health equity, are the need to target a defined population, the importance of understanding the context of the intervention (including social context and infrastructure through which the study must be actualized), and the necessity of ensuring sustainability. Study methods can then be varied to effectively study a specific problem. Studies can be quantitative, qualitative, or mixed methods so long as it operates within the chosen framework.

Further, in this Scientific Statement, the authors push us to examine the current state of the literature. There are numerous notable and necessary studies that have identified health disparities in heart failure. These are important so that we can understand the extent of the problem and begin to consider solutions. Few studies have specifically examined the role or concept of implementation science in heart failure generally. Even fewer have taken a cross-cutting lens to consider how implementation science might be used to specifically address health equity in heart failure. An approach like this has several benefits which the authors highlight including the engagement of diverse stakeholders (including community members) who are key to both the development of and sustainability of interventions; a focus on assessing and addressing structural determinants of health like the social determinants of health and racism; and inclusion of outcome measures that center health equity.

Authors identified only three studies in the literature that specifically used implementation science to work toward equity in heart failure. The study Seeking Objectivity in Allocation of Advanced HF Therapies (SOCIAL HF) serves as a prototype for these types of studies, specifically in the realm of advanced therapies for heart failure. The researchers targeted issues like bias and team dynamics with their intervention. Follow up studies across a larger population show promise. Other cited studies look to the diverse stakeholders that are an integral part of heart failure care and have tried to implement change through their engagement and training.

While these studies are important additions to the literature, there are simply too few. To that end, the Scientific Statement by Breathett et al. is a call to action. No longer can we sit idly by and allow structural inequities that are baked into our system to contribute to poorer outcomes for vulnerable patients. It is important to identify health disparities in HF. It's equally important to develop a rigorous, evidence-based approach to addressing these disparities. An approach that incorporates the tenets of implementation science can do just that. Health equity in heart failure is not a destination. We should constantly be striving to be better than we were before. This requires strengthening funding mechanisms, supporting investigators who are passionate about this work, and mentoring the next generation of clinicians and researchers to ensure that they are equipped to take on this fight. In the end, health equity must be woven into the fabric of everyday care. Just as our standard for excellence is set, so too must that standard be for all patients.