Gaps in Variation of Heart Failure Care
In negative trials, the clinical heterogeneity of patient population is sometimes invoked as a reason why a therapy does not reach statistical significance. However, from a population perspective, most RCTs that form the current evidence base do not randomise a sufficient number of women and underrepresented minorities, thus limiting their generalizability. Women and various racial and ethnic groups have significant differences in aetiology of HF and response to treatment due to underlying biological differences and disparities in healthcare utilisation.82 Future trials should strive to enrol higher proportions of these underrepresented populations. Encouragingly, data from the Get With The Guidelines®-Heart Failure registry shows that a concerted national quality improvement programme can deliver equally effective care across racial and ethnic groups.83
In clinical trials, the impact of therapy on quality of life can sometimes be deemed less important than the primary endpoint of mortality. This issue is particularly relevant for very elderly patients or patients with poor long-term prognosis, where symptom control may be more valuable than mortality benefits. Additionally, palliative services and hospice remain underutilised in patients with advanced HF, especially when compared with patients with cancer.84 Determining the optimal timing and palliative care approach is difficult in HF because of the undulating course of disease and availability of advanced therapies for end-stage HF, such as heart transplantation and ventricular assist devices.