A challenge to equity in transplantation: Increased center-level variation in short-term mechanical circulatory support use in the context of the updated U.S. heart transplant allocation policy

Thomas M. Cascino, Josef Stehlik, Wida S. Cherikh, Yulin Cheng, Tessa M.F. Watt, Alexander A. Brescia, Michael P. Thompson, Jeffrey S. McCullough, Min Zhang, Supriya Shore, Jessica R. Golbus, Francis D. Pagani, Donald S. Likosky, Keith D. Aaronson

Research output: Contribution to journalArticlepeer-review

17 Scopus citations

Abstract

Background: The United States National Organ Procurement Transplant Network (OPTN) implemented changes to the adult heart allocation system to reduce waitlist mortality by improving access for those at greater risk of pre-transplant death, including patients on short-term mechanical circulatory support (sMCS). While sMCS increased, it is unknown whether the increase occurred equitably across centers. Methods: The OPTN database was used to assess changes in use of sMCS at time of transplant in the 12 months before (pre-change) and after (post-change) implementation of the allocation system in October 2018 among 5,477 heart transplant recipients. An interrupted time series analysis comparing use of bridging therapies pre- and post-change was performed. Variability in the proportion of sMCS use at the center level pre- and post-change was determined. Results: In the month pre-change, 9.7% of patients were transplanted with sMCS. There was an immediate increase in sMCS transplant the following month to 32.4% - an absolute and relative increase of 22.7% and 312% (p < 0.001). While sMCS use was stable pre-change (monthly change 0.0%, 95% CI [-0.1%,0.1%]), there was a continuous 1.2%/month increase post-change ([0.6%,1.8%], p < 0.001). Center-level variation in sMCS use increased substantially after implementation, from a median (interquartile range) of 3.85% (10%) pre-change to 35.7% (30.6%) post-change (p < 0.001). Conclusions: Use of sMCS at time of transplant increased immediately and continued to expand following heart allocation policy changes. Center-level variation in use of sMCS at the time of transplant increased compared to pre-change, which may have negatively impacted equitable access to heart transplantation.

Original languageEnglish
Pages (from-to)95-103
Number of pages9
JournalJournal of Heart and Lung Transplantation
Volume41
Issue number1
DOIs
StatePublished - Jan 2022

Keywords

  • ethics
  • health equity
  • heart transplant allocation
  • heart transplantation
  • public policy

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