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Original Investigation
April 15, 2020

Transplant Center Variability in Organ Offer Acceptance and Mortality Among US Patients on the Heart Transplant Waitlist

Author Affiliations
  • 1Medical student, School of Medicine, Duke University, Durham, North Carolina
  • 2Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
  • 3Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
  • 4Division of Cardiology, Duke University Medical Center, Durham, North Carolina
JAMA Cardiol. Published online April 15, 2020. doi:10.1001/jamacardio.2020.0659
Key Points

Question  Is transplant center variability in offer acceptance associated with mortality among patients on the heart transplant waitlist?

Findings  In this cohort study of 9628 candidates for heart transplant over 10 years, every 10% increase in adjusted center acceptance rate of offers made to the highest-priority candidates was associated with a 27% reduction in the rate of mortality among patients on the waitlist, with no detriment in 5-year adjusted posttransplant patient survival or graft failure.

Meaning  The center-level decision to accept or decline an allograft may represent a modifiable behavior that is associated with mortality among patients on the heart transplant waitlist.

Abstract

Importance  Under the current Centers for Medicare & Medicaid Services guidelines, there is incentivization to optimize posttransplant outcomes regardless of mortality among patients on the waitlist and transplant rates; few data exist with regard to transplant center acceptance practices and survival to heart transplant.

Objectives  To evaluate the extent of variability in organ acceptance practices in the US and whether this center-level behavior is associated with heart transplant candidate survival.

Design, Setting, and Participants  In this retrospective cohort study, the US National Transplant Registry was queried for all match runs of adult candidates listed for isolated heart transplant between May 1, 2007, and March 31, 2017. Data analysis was conducted from October 30, 2018, to May 1, 2019. The final cohort included 93 transplant centers, 19 703 donors, and 9628 candidates.

Main Outcomes and Measures  Center acceptance rates for heart allografts offered to the highest-priority candidates, association between center acceptance rate and mortality among patients on the waitlist, and posttransplant outcomes between candidates who accepted their first-rank offers vs those who accepted previously declined offers.

Results  Among 19 703 unique organ offers, 6302 hearts (32.0%) were accepted for first-rank candidates. After adjustment for donor, candidate, and geographic covariates, transplant centers varied in acceptance rates (12.3%-61.5%) of offers made to first-rank candidates. Higher acceptance rates were associated with lower cumulative incidence of 1-year mortality among patients on the waitlist. For every 10% increase in adjusted center acceptance rate, the risk of mortality decreased by 27% (subdistribution hazard ratio, 0.73; 95% CI, 0.67-0.80). No statistically significant difference was observed in 5-year adjusted posttransplant patient survival (adjusted hazard ratio, 1.02; 95% CI, 0.94-1.11) and graft failure (subdistribution hazard ratio; 0.95; 95% CI, 0.83-1.09) between hearts accepted at the first-rank compared with lower-rank positions.

Conclusions and Relevance  Variability in heart allograft acceptance rates appears to exist among transplant centers, with candidates listed at lower acceptance rate centers being more likely to experience mortality while on the waitlist. Comparable posttransplant survival suggests that allografts that were declined as a first offer perform as well as those that were accepted at their first offer. These findings suggest that organ acceptance rate or time to transplant from being added to the waitlist may be an additional measure of heart transplant program performance.

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