Impact of the 2018 change in US allocation policy on adults with congenital heart disease.

BACKGROUND: The US adult heart allocation policy was changed on October 18, 2018. This study aims to evaluate its impact on orthotopic heart transplantation (OHT) for adults with congenital heart disease (ACHD). METHODS: The United Network for Organ Sharing database was used to perform 2 comparisons: waitlist outcomes among listed ACHD candidates, and post-transplant outcomes in those transplanted. Waitlisted candidates were stratified by date of waitlisting: Period 1: 2010 to 2013; Period 2: 2014 to October 17, 2018 and Period 3: October 18, 2018 to March 20, 2020. Transplanted ACHD patients were similarly stratified but by date of transplantation. Competing risk regression for waitlist outcomes was performed. Post-transplant survival was analyzed using the Kaplan-Meier method and multivariable Cox regression. RESULTS: Nine hundred and seventy-six patients with ACHD were waitlisted for OHT in our study: 343(35.1%), 466(47.8%), and 167(17.1%) in periods 1, 2, and 3. Post-policy change, 1-year cumulative incidence of waitlist mortality or deterioration decreased (p = 0.02). Six hundred and forty-eight patients were transplanted: 221(34.1%), 329(50.8%) and 98(15.1%) respectively. In those transplanted, post-policy median waitlist time (174, 161 and 38 days, p < 0.001) decreased and the use of intra-aortic balloon pumps increased (1.4%, 4.9% and 19.4%, p < 0.001). Compared to periods 1 and 2, risk-adjusted post-transplant 1-year mortality was similar to period 3 (HR 1.10, 95% CI 0.52-2.32; p = 0.81) (HR 1.19, 95% CI 0.58-2.46, p = 0.63). CONCLUSIONS: The recent US allocation policy change may have resulted in reduced waitlist times and 1-year waitlist mortality for OHTs in ACHD patients. Early post-transplant outcomes appear comparable post-policy change.

Geographic disparities in heart transplantation persist under the new allocation policy.

BACKGROUND: This study evaluated the impact of the 2018 heart allocation policy change on geographic disparities in United States orthotopic heart transplantation (OHT). METHODS: The United Network for Organ Sharing registry was queried to measure geographic disparity in OHT rates between pre-policy and post-policy change eras. We performed multilevel Poisson regression to measure region-level OHT rates. We derived an allocation priority-adjusted median incidence rate ratio (MIRR) for each policy era, a measure of median change in OHT rates between regions. RESULTS: 5958.78 waitlist person-years were analyzed, comprising 6596 OHT procedures (3890 pre-policy and 2706 post-policy). Median region-level OHT rate was .94 transplants/person-years before and 1.51 transplants/person-years after the policy change (P < .001). The unadjusted OHT MIRR across regions was 1.29 (95% CI 1.00-1.50) pre-policy change and 1.17 (95% CI 1.00-1.43) post-policy change, suggesting that the region-related variance in OHT rates decreased under the new allocation. After adjustment for allocation priority risk factors, the MIRR pre-policy change was 1.13 (95% CI 1.01-1.32) and post-policy change was 1.15 (95% CI 1.00-1.35). CONCLUSIONS: Geography accounts for ∼10% of the disparity among United States OHT rates. Despite broader heart sharing, the updated allocation policy did not substantially alter the existing geographic disparities among OHT recipients.