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Regional variation in survival before and after pediatric heart transplantation--an analysis of the UNOS database
R R Davies1, S Haldeman, C Pizarro
1Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, DE, USA. rdavies@nemours.org
Insights
Geographic disparities impact pediatric heart transplant waitlist times and mortality. Regions with more transplant centers and fewer donors show worse outcomes, highlighting the need for equitable organ allocation.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Health Services Research
Background:
- Geographic variation in health outcomes is well-documented.
- Regional influences on pediatric heart transplantation outcomes, both pre- and post-listing, remain under-assessed.
- Understanding these regional disparities is crucial for improving pediatric heart transplant care.
Purpose of the Study:
- To assess regional variations in outcomes for pediatric patients listed for heart transplantation.
- To identify factors associated with geographic differences in waitlist mortality and post-transplant survival.
- To inform strategies for equitable allocation of cardiac allografts.
Main Methods:
- Utilized the United Network for Organ Sharing (UNOS) dataset for 5398 pediatric patients (≤ 18 years) listed between 2000-2011.
- Stratified patients by listing region and correlated regional variables with risk-adjusted individual outcomes.
- Analyzed waitlist time, waitlist mortality, and post-transplant survival across different regions.
Main Results:
- Significant geographic variation in mean waitlist time (91.0 ± 163 days in R6 to 248.1 ± 493 days in R4).
- Higher waitlist mortality in regions with more transplant centers and fewer transplants per center.
- Waitlist mortality was higher with more listings per center (OR 1.04) and lower with more donors per center (OR 0.95).
- Post-transplant survival varied regionally, but regional variables did not correlate with these outcomes.
Conclusions:
- Pediatric heart transplant outcomes exhibit significant geographic variation.
- Increased competition for donor organs, influenced by regional factors, is linked to poorer waitlist survival.
- Further investigation is needed to ensure equitable cardiac allograft allocation across all regions.
Abstract:
Geographic variation occurs in a variety of health outcomes. Regional influences on outcomes before and after listing for pediatric heart transplantation have not been assessed. Review of the UNOS dataset identified 5398 pediatric (≤ 18 years) patients listed for heart transplantation 2000-2011. Patients were stratified based on the region of listing. Regional-level variables were correlated with individual risk-adjusted outcomes. Mean time spent on the waitlist varied from 91.0 ± 163 days (Region 6 [R6]) to 248.1 ± 493 days (R4, p < 0.0001). Regions with more transplant centers (p < 0.0001) and fewer transplants (p = 0.0015) had higher waitlist mortality. Risk-adjusted individual waitlist mortality varied from 6.9% (R1, CI 6.2-7.8) to 19.2% (R5, CI 18.0-20.6). Waitlist mortality was higher for individuals awaiting transplant in regions with more listings per center (OR 1.04, CI 1.01-1.08) and lower in regions with more donors per center (OR 0.95, CI 0.90-0.99 per donor). Posttransplant risk-adjusted survival varied across regions (R4: 5.4%, CI 4.2-7.4; R7: 18.0%, CI 12.4-32.5), but regional variables were not correlated with outcomes. Outcomes among children undergoing heart transplantation vary by region. Factors leading to increased competition for donor allografts are associated with poorer waitlist survival. Equitable allocation of cardiac allografts requires further investigation of these findings.
