Heart Transplant Equity: Effect of 2018 Allocation Policy Change on Recipient Mortality and Morbidity by Race and Ethnicity.

Abstract

Background: In 2018, the US heart allocation policy was changed from 3 tiers to 6 tiers for a more granular assessment of patients' medical urgency. Given previous studies showing significant discrepancies in posttransplantation outcomes among Black and Hispanic minority groups, we investigated the effects of the allocation policy change on these groups.

Study design: Adult heart transplantation patients from October 18, 2014, to October 18, 2022, were included from the United Network for Organ Sharing database. Multiorgan transplants and retransplants were excluded. One to one propensity matching was performed by race and ethnicity and allocation score era. The primary outcome was overall (4-year) survival assessed using multivariable Cox regression in an unmatched cohort; secondary outcomes were in-hospital and 1-year rejection, short-term mortality, and graft failure, assessed using conditional logistic regression in the matched cohort.

Results: The total cohort included 19,731 patients; 13,001 White, 4,784 Black, and 1,946 Hispanic. White, Black, and Hispanic cohorts in matched analysis demonstrated postallocation change improvements in in-hospital and 1-year rejection (all p < 0.05) and comparable short-term mortality and graft failure (all p > 0.05). In adjusted analyses, Black recipients had comparable overall mortality to White recipients both pre- (adjusted hazard ratio [aHR] 1.04 [0.92, 1.18], p = 0.514) and postallocation change (aHR 1.10 [0.95, 1.27], p = 0.194). Postallocation change, Black recipients had a higher risk of overall mortality (aHR 1.20 [1.01, 1.42], p = 0.033), whereas Hispanic recipients had lower risk of mortality (aHR 0.72 [0.55, 0.94], p = 0.015) compared with White recipients.

Conclusions: This analysis demonstrates improved acute rejection rates postallocation change, by race and ethnicity; however, there remain disparities in short- and long-term recipient mortality for Black recipients in the postallocation change era. Future studies will explore the factors impacting long-term survival among these groups.