Great variability in donor heart acceptance practices across the United States

Abstract

Disparities in organ acceptance practices exacerbate donor heart nonuse and lead to increased waiting times and mortality for heart transplant candidates. We studied disparities in donor heart acceptance among US transplant centers and their relations to posttransplant outcomes. Candidate, potential transplant recipient match run, and deceased donor data were obtained from the United Network for Organ Sharing. We analyzed donor, candidate, and transplant center characteristics with respect to organ acceptance, offer acceptance, number of offers before acceptance (organ sequence number), and association with posttransplant mortality. A total of 693 420 donor heart offers made between April 2007 and December 2015 were included. We identified great variability in donor heart acceptance practices among US heart transplant centers. We identified donor and recipient characteristics that were strongly associated with heart organ and offer acceptance, and organ sequence number, and identified inconsistencies among centers with respect to how these characteristics influenced acceptance decisions. Finally, we identified characteristics that were highly predictive of donor heart nonuse and were not associated with increased recipient mortality, which may guide future efforts aimed at increasing use of available hearts for transplantation.

Keywords: clinical research/practice; donors and donation; heart transplantation/cardiology; organ acceptance; organ procurement and allocation.

Figure 1:

Exclusion criteria for transplant candidates, donors, and donor heart offers from April 2007 to December 2015

Figure 2:

Overview of statistical analyses performed (MAD: median absolute deviation)

Figure 3:

Access rate, by transplant center volume (very low=0-12/year, low=13-21/year, medium=22-33/year, high>33/year)

Figure 4:

Median organ sequence number, by transplant centers’ donation service area. Grey areas indicate areas excluded due to lack of data (see Detailed Methods in the Supplemental Material)

Figure 5:

Donor and candidate characteristics that demonstrated the greatest inconsistency between transplant centers, by offer acceptance, organ acceptance, and organ sequence number. Transplant centers were most inconsistent in how they weighed donor age and height in the decision process. Characteristics that were not predictive of recipient post-transplant mortality are highlighted with an asterix (*) and represent key characteristics that can be targeted to safely increase donor heart utilization. BUN: blood urea nitrogen, LV: left ventricular, EF: ejection fraction, COD; cause of death

Figure 6:

A: Donor and recipient characteristics most predictive of mortality or re-transplantation within 30 days. Red circles indicate that the characteristic (e.g. race) and the category (e.g. multiracial) were predictive of both 30-day and 1-year mortality or re-transplantation. Grey circles indicate that the characteristic is predictive of both 30-day and 1-year mortality or re-transplantation, but not the category (for example, transplant center volume is associated with both 30-day and 1-year mortality or re-transplantation, but high volume is associated with 30-day mortality and medium volume is associated with 1-year mortality). B: Donor and recipient characteristics most predictive of mortality or re-transplantation within 1 year. Red circles indicate that the characteristic (e.g. race) and the category (e.g. multiracial) were predictive of both 30-day and 1-year mortality or re-transplantation. Grey circles indicate that the characteristic is predictive of both 30-day and 1-year mortality or re-transplantation, but not the category (for example, transplant center volume is associated with both 30-day and 1-year mortality or re-transplantation, but high volume is associated with 30-day mortality and medium volume is associated with 1-year mortality).

Figure 6:

A: Donor and recipient characteristics most predictive of mortality or re-transplantation within 30 days. Red circles indicate that the characteristic (e.g. race) and the category (e.g. multiracial) were predictive of both 30-day and 1-year mortality or re-transplantation. Grey circles indicate that the characteristic is predictive of both 30-day and 1-year mortality or re-transplantation, but not the category (for example, transplant center volume is associated with both 30-day and 1-year mortality or re-transplantation, but high volume is associated with 30-day mortality and medium volume is associated with 1-year mortality). B: Donor and recipient characteristics most predictive of mortality or re-transplantation within 1 year. Red circles indicate that the characteristic (e.g. race) and the category (e.g. multiracial) were predictive of both 30-day and 1-year mortality or re-transplantation. Grey circles indicate that the characteristic is predictive of both 30-day and 1-year mortality or re-transplantation, but not the category (for example, transplant center volume is associated with both 30-day and 1-year mortality or re-transplantation, but high volume is associated with 30-day mortality and medium volume is associated with 1-year mortality).