Date of Award


Degree Name

Doctor of Philosophy


Interdisciplinary Health Sciences

First Advisor

Kieran Fogarty, Ph.D.

Second Advisor

Kata Chillag, Ph.D.

Third Advisor

Michael Dickinson, M.D.

Fourth Advisor

Rob Lyerla, Ph.D., M.S.


Access, health equity, heart transplantation, social determinants of health, social disparities, structural barriers


Patients with end-stage advanced heart failure must go through an extensive evaluation process before being selected for either heart transplantation or left ventricular assist device (LVAD). This evaluation not only assesses a patient’s medical need for advanced heart failure treatments but also includes an assessment of psychosocial and economic factors that may affect a patient’s success post-treatment. While it is important to allocate scarce resources, such as donated organs, to the patients who will benefit the most, there is also a need for equity in the allocation of and access to healthcare services. This raises the question of whether patients who are diagnosed with heart failure ever have the opportunity to be evaluated for advanced heart failure services in the first place, due to gatekeeping events that may prevent patients from being referred to or have an appointment with a specialist.

The independent variables age, sex, marital status race/ethnicity, preferred language, smoking status, and insurance status were compared between patients referred and not referred, who had a clinic visit and did not have a clinic visit, and who received treatment and did not receive treatment. Patients who were younger (HR 0.934, 95% CI 0.925, 0.943), males (HR 2.216, 95% CI 1.544, 3.181), married (HR 0.665, 95% CI 0.488, 0.905), or non-smokers (HR 0.549, 95% CI 0.389, 0.776) were more likely to be referred to a specialist. Married patients (p=0.024) and nonsmokers (p=0.039) were more likely to have a clinic visit and younger age was shown to contribute as well (HR 0.981, 95% CI 0.966, 0.995). Younger age (B coefficient = - 0.21; HR 0.980 [95% CI 0.961, 0.998]), White race (p=0.042), Hispanic/Latino ethnicity (B coefficient = 1.504; HR 4.501 [95% CI 1.574, 12.875]), and both public (B coefficient = -0.758; HR 0.468 [95% CI 0.270, 0.813]) and private insurance (p=0.027) were significantly influencing whether patients received a heart transplant. Hispanic ethnicity was also associated with receiving an LVAD (HR 33.833, 95% CI 3.207, 356.968). Advanced age, Hispanic ethnicity, and smoking were associated with one-year mortality after heart failure diagnosis.

This study confirmed that disparities in access exist before patients are ever evaluated for advanced heart failure therapies. The gatekeeping events preventing patients from referral are multifactorial and based on historical injustices and structural barriers outside of the scope of healthcare. Recommendations for improving equity in access include improved heart failure guidelines for referral, cultural bias training for healthcare professionals, and government-led initiatives to provide universal financing for transplantation.

Access Setting

Dissertation-Open Access