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 post-transplant outcomes among Black and Hispanic minority groups, we investigated the effects of the allocation policy change on these groups.

Methods: Adult heart transplant patients from 10/18/2014-10/18/2022 were included from the United Network for Organ Sharing (UNOS) database. Multiorgan transplants and retransplants were excluded. 1:1 propensity-matching were performed by race/ethnicity and allocation score era. Primary outcome was overall(4-year) survival assessed using multivariable Cox regression in 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, 4784 Black, and 1946 Hispanic. White, Black, and Hispanic cohorts in matched analysis demonstrated post-allocation 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- (aHR=1.04[0.92,1.18], p=0.514) and post-allocation change (aHR=1.10[0.95,1.27], p=0.194). Post-allocation change, Black recipients had a higher risk of overall mortality (aHR=1.20[1.01,1.42], p=0.033) while Hispanic recipients had lower risk of mortality (aHR=0.72[0.55,0.94], p=0.015) compared to White recipients.

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