ABSTRACT Bias is present in multiple facets of life and influences decision-making particularly among racial/ethnic minorities. Bias also likely plays a strong role in the process of selecting candidates for advanced heart failure therapies, including heart transplants and left ventricular assist devices, because of the subjective nature of the process. Implicit bias has been well studied in medicine but has not been found to be universally instrumental in changing outcomes, and healthcare group decision-making has not been well studied. Therefore, the application of mixed-methods to study individual healthcare provider bias and group decision-making is innovative. For the first time, the think aloud protocol, a method of elucidating decision-making thoughts for thematic qualitative analysis, and a visual analog scale survey will be used to assess individual provider bias, and the de Groot Critically Reflective Diagnosis protocol, a methodical quantification of reflective group decision-making, will be used to assess the group decision-making process for selection of candidates for advanced therapy for heart failure. We will identify the single most important subjective factor that contributes to racial/ethnic bias and lower reflective scores. An objective measurement of this factor will be used in a standardized protocol for evaluating patients for advanced therapies. Naturalistic evaluation of implementation of this protocol will lead to protocol tailoring that will provide groundwork for a pragmatic R01 trial. The findings of this study will also have implications for other populations that use multidisciplinary healthcare providers for decision-making such as selection of patients for transcatheter aortic valve replacement and transplantation of other organs.

PROJECT NARRATIVE Understanding the role of bias in the selection of patients for advanced heart failure therapies is a critical step in creating health equity. This study will examine individual provider bias and the group decision-making process for selecting patients for advanced therapies for heart failure, heart transplants and left ventricular assist devices. We will identify the most important subjective eligibility criterion for advanced therapies and implement a standardized protocol that objectively measures this criterion.