Disparities in Heart Transplant Waitlist Outcomes in Rural Communities in the Current United Network for Organ Sharing Allocation System

Document Type

Conference Proceeding

Publication Date

2025

Publication Title

Journal of Cardiac Failure

Abstract

Introduction: The heart transplant (HT) allocation implemented in 2018 resulted in reduced waitlist times, increased rates of transplantation, and a wider geographic range of organ allocation. The impact of the allocation system on rural communities has not been evaluated. We compared the outcomes in the waitlist and after transplantation in rural and urban communities in the current and prior allocation systems.

Methods: Adult patients listed for HT in UNOS from 1/1/2014-12/31/2021 were enrolled. Patients undergoing re-transplantation or multi-organ transplantation were excluded. Patients were then categorized in rural or urban residence according to zip code. Patients were categorized in the prior or current allocation system depending on whether they were listed before or after Oct 18, 2018. Cumulative Incidence (CI) of outcomes in the waitlist (transplantation or death/delisting due to worsening clinical status) were calculated. One-year survival after HT was calculated using Kaplan-Meier methodology. Comparisons between rural and urban residents in the prior and current allocation systems were performed before and after adjustment for risk factors.

Results: A total of 26450 patients were listed for HT, of which 59.6% and 40.4% were listed in the prior and current allocation systems, respectively; 17796 patients underwent transplantation. Of the 15761 listed under the previous UNOS policy, 19.2% were of rural residence and 80.8% urban; of the 10689 listed under the current policy, 18.9% were rural and 81.1% urban. Of the patients that underwent transplant, 9424 were listed under the previous system with 18.9% rural and 81.1% urban; 8372 were listed under the current system with 18% rural and 82% urban. In the prior allocation system the CI of death/delisting and transplantation was not different between rural or urban residents in the unadjusted or adjusted models. In the current system the unadjusted models demonstrated a trend towards higher CI of death/delisting for rural residents (7.4% vs 6.2%; p=0.06) and lower CI of heart transplant (65.8% vs 68.2%; p=0.07). In adjusted models rural residence was independently associated with a higher CI of death/delisting(HR 1.29 95% CI 1.06-1.57; p=0.01). In addition, rural residents had a higher CI of transplantation (HR 1.09 95% CI 1.02-1.17; p=0.011). The adjusted and unadjusted post-transplant survival were similar between rural and urban residents both in the prior and current systems.

Conclusions: While the change in the UNOS heart organ allocation system has resulted in some benefits, it may be associated with inequitable geographical bias towards increased death/delisting in rural residents and decreased HT amongst urban. The cause of these potential inequities requires further investigation. The data reported here have been supplied by the United Network for Organ Sharing as the contractor for the Organ Procurement and Transplantation Network. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy of or interpretation by the OPTN or the U.S. Government.

Volume

31

Issue

1

First Page

316

Comments

Heart Failure Society of America (HFSA) Annual Scientific Meeting, September 27-30, 2024, Atlanta, GA

Frederik Meijer Heart & Vascular Institute

Last Page

316

DOI

10.1016/j.cardfail.2024.10.343

ISSN

1532-8414

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