Evaluating the intersectionality of race and gender and its impact on heart transplant equity, listing outcomes, and allocation policy.

Background: Although there are existing studies on the role of race- and gender-based disparities as one-dimensional elements in heart transplantation (HTx), few reports have examined the intersection of such identities. Our study investigates the intersectionality of race and gender, and its impact on HTx waitlist outcomes.

Methods: Data from adult patients listed for orthotopic HTx between 2010 and 2023 were analyzed using the United Network for Organ Sharing database. Inclusion criteria included "White" and "Black" races. Exclusion criteria included missing data in race or gender, a previous history of HTx, or concurrent listing for other transplants. Four groups were created using a combination of race and gender. Waitlist outcomes of interest include transplantation and death using competing-risk models.

Results: In total, 37,796 patients were included in this analysis, of which 55.1 % were White-male (M), 17.4 % White-female (F), 18.6 % Black-M, and 8.9 % Black-F. Relative to White-M, Black-M (HR = 0.86, p < 0.001) and Black-F (HR = 0.82, p < 0.001) had decreased odds of transplantation. In the survival models, both female groups had a decreased mortality risk compared to White-M (White-F: HR = 0.56, p = 0.001; Black-F: HR = 0.61, p = 0.008) and Black-M (White-F: HR = 0.60, p = 0.005; Black-F: HR = 0.64, p = 0.025). Following the 2018 policy changes, with reference to White-F, Black-M (0.94, p = 0.189) had comparable odds of HTx while Black-F (HR = 0.91, p = 0.618) had a similar pattern of survival.

Conclusion: Disparities on the HTx waiting list continue to exist. Black patients had decreased odds of transplantation compared to White groups. Additionally, females had superior overall survival on the waitlist. Although outcomes appear to have improved marginally for some vulnerable groups in the new allocation system, further work is required to achieve equity on the heart transplant waiting list.