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Original Investigation
November 12, 2019

Association of Transplant Center With Survival Benefit Among Adults Undergoing Heart Transplant in the United States

Author Affiliations
  • 1Department of Medicine, University of Chicago, Chicago, Illinois
  • 2MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
  • 3Department of Public Health Sciences, University of Chicago, Chicago, Illinois
  • 4Department of Medicine, Northwestern University, Chicago, Illinois
  • 5Department of Pediatrics, University of Chicago, Chicago, Illinois
JAMA. 2019;322(18):1789-1798. doi:10.1001/jama.2019.15686
Key Points

Question  Is there an association between transplant center and the survival benefit associated with heart transplant in the United States?

Findings  In this registry-based observational study of 29 199 candidates for heart transplant in the United States, the 5-year survival benefit associated with heart transplant ranged from 30% to 55%. Estimated waiting list survival without transplant was significantly lower at centers with survival benefits significantly above the mean compared with those below the mean (29% at high survival benefit centers vs 39% at low survival benefit centers), but there was no significant difference in survival after the transplant (77.6% vs 77.1%, respectively).

Meaning  The 5-year survival benefit associated with heart transplant varied across transplant centers, and high survival benefit centers performed heart transplant for patients with lower estimated waiting list survival without transplant.

Abstract

Importance  In the United States, the number of deceased donor hearts available for transplant is limited. As a proxy for medical urgency, the US heart allocation system ranks heart transplant candidates largely according to the supportive therapy prescribed by transplant centers.

Objective  To determine if there is a significant association between transplant center and survival benefit in the US heart allocation system.

Design, Setting, and Participants  Observational study of 29 199 adult candidates for heart transplant listed on the national transplant registry from January 2006 through December 2015 with follow-up complete through August 2018.

Exposures  Transplant center.

Main Outcomes and Measures  The survival benefit associated with heart transplant as defined by the difference between survival after heart transplant and waiting list survival without transplant at 5 years. Each transplant center’s mean survival benefit was estimated using a mixed-effects proportional hazards model with transplant as a time-dependent covariate, adjusted for year of transplant, donor quality, ischemic time, and candidate status.

Results  Of 29 199 candidates (mean age, 52 years; 26% women) on the transplant waiting list at 113 centers, 19 815 (68%) underwent heart transplant. Among heart transplant recipients, 5389 (27%) died or underwent another transplant operation during the study period. Of the 9384 candidates who did not undergo heart transplant, 5669 (60%) died (2644 while on the waiting list and 3025 after being delisted). Estimated 5-year survival was 77% (interquartile range [IQR], 74% to 80%) among transplant recipients and 33% (IQR, 17% to 51%) among those who did not undergo heart transplant, which is a survival benefit of 44% (IQR, 27% to 59%). Survival benefit ranged from 30% to 55% across centers and 31 centers (27%) had significantly higher survival benefit than the mean and 30 centers (27%) had significantly lower survival benefit than the mean. Compared with low survival benefit centers, high survival benefit centers performed heart transplant for patients with lower estimated expected waiting list survival without transplant (29% at high survival benefit centers vs 39% at low survival benefit centers; survival difference, −10% [95% CI, −12% to −8.1%]), although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers (77.6% vs 77.1%, respectively; survival difference, 0.5% [95% CI, −1.3% to 2.3%]). Overall, for every 10% decrease in estimated transplant candidate waiting list survival at a given center, there was an increase of 6.2% (95% CI, 5.2% to 7.3%) in the 5-year survival benefit associated with heart transplant.

Conclusions and Relevance  In this registry-based study of US heart transplant candidates, transplant center was associated with the survival benefit of transplant. Although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers, compared with centers with survival benefit significantly below the mean, centers with survival benefit significantly above the mean performed heart transplant for recipients who had significantly lower estimated expected 5-year waiting list survival without transplant.

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