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UNOS policy change benefits high-priority patients without harming those at low priority
Aaron M Wolfson1,2, Eugene C DePasquale1,2, Michael W Fong1,2
1Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
Insights
The heart transplantation policy change improved outcomes for high-priority patients without negatively impacting low-priority patients. Low-priority patients saw a trend toward reduced waitlist death and increased heart transplants post-policy change.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Policy
Background:
- A recent heart transplantation policy change (PC) aimed to improve outcomes for high-acuity patients.
- The impact of this policy change on low-priority heart transplant candidates remained unclear.
Purpose of the Study:
- To assess if the benefits to high-priority patients compromised outcomes for low-priority candidates.
- To evaluate the interaction between the policy change and patient priority status on transplant outcomes.
Main Methods:
- Utilized data from the UNOS registry for adult first-time heart transplant candidates and recipients.
- Analyzed clinical characteristics and performed competing risks and survival analyses.
- Stratified analyses by policy change status and patient priority status.
Main Results:
- An interaction was found between the policy change and priority status regarding waitlist death/deterioration (adjusted sdHR: 0.59).
- Low-priority patients showed a trend towards reduced waitlist death/deterioration (adjusted sdHR: 0.86) and increased heart transplantation (adjusted sdHR: 1.08).
- No significant difference in 1-year post-transplant survival was observed for low-priority patients after the policy change.
Conclusions:
- The heart transplantation policy change did not negatively affect waitlisted or transplanted low-priority patients.
- High-priority patients experienced a targeted reduction in waitlist mortality without compromising post-transplant survival.
- The policy change successfully benefited high-priority patients without adverse consequences for low-priority candidates.
Abstract:
The heart transplantation policy change (PC) has improved outcomes in high-acuity (Old 1A, New 1-3) patients, but the effect on low-priority (Old 1B/2, New 4-6) patients is unknown. We sought to determine if low-priority patient outcomes were compromised by benefits to high-priority patients by evaluating for interaction between PC and priority status (PS). We included adult first-time heart transplant candidates and recipients from the UNOS registry during a 19-month period before and after the PC. We compared clinical characteristics and performed competing risks and survival analyses stratified by PC and PS. There was a dependence of PC and PS on waitlist death/deterioration with an interaction sub-distribution hazard ratio (adjusted sdHR) of 0.59 (0.45-0.78), p-value < .001. There was a trend toward a benefit of PC on waitlist death/deterioration (adjusted sdHR: 0.86 [0.73-1.01]; p = .07) and an increase in heart transplantation (adjusted sdHR: 1.08 [1.02-1.14], p = .007) for low-priority patients. There was no difference in 1-year post-transplant survival (log-rank p = .22) when stratifying by PC and PS. PC did not negatively affect waitlisted or transplanted low-priority patients. High-priority, post-PC patients had a targeted reduction in waitlist death/deterioration and did not come at the expense of worse post-transplant survival.
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