Improvement in Racial Disparities in Heart Transplantation following the Heart Allocation Policy Change

Objectives. Heart transplantation (HT) is a definitive therapy for refractory heart failure, making it the gold-standard treatment for recipients with end-stage disease. Heart allocation policy (HAP) in the United States was changed on October 18th, 2018. The aim of this study was to assess the effect of the new policy on racial disparities in heart transplantation (HT) outcomes. Methods. The United Network for Organ Sharing (UNOS) registry was used to identify adult recipients undergoing isolated HT between 2010 and 2021. Recipients were stratified into pre-HAP (January 2010 to September 2018) vs. post-HAP (October 2018 to September 2021). Recipient race was classified as White, Black, Hispanic, or other. The primary outcome was post-HT mortality. Cox proportional hazard models were used for risk-adjustment in evaluating the independent effect of race on post-HT mortality. Results. A total of 27,403 recipients underwent HT in 143 centers during study period. The proportion of non-Whites undergoing HT increased in the post-HAP era: (pre-HAP: White 66.0%, Black 21.2%, Hispanic 8.2%, Other 4.6% versus post-HAP: White 62.5%, Black 23.2%, Hispanic 9.5%, Other 4.8%; p < 0.001 ). In risk-adjusted analysis, Black recipients were at higher risk of post-HT mortality in the pre-HAP era (HR 1.31, 95% CI 1.22–1.41; p < 0.001 ) but not in the post-HAP era (HR 1.12, 95% CI 0.03–1.34; p = 0.222 ) compared to White recipients. Other non-White recipients had comparable risk-adjusted post-HT mortality rates compared to White recipients both in the pre-HAP and post-HAP eras. Conclusions. Under the new heart allocation system, a higher percentage of recipients are non-White. In addition, racial disparities in HT outcomes have improved with Black recipients no longer having an increased risk-adjusted mortality following HT.