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Impact of 2016 UNOS pediatric heart allocation policy changes on VAD utilization, waitlist, and post-transplant
Bibhuti B Das1, Chad T Blackshear2, Seth T Lirette2
1Heart Center, Mississippi Children's Hospital, University of Mississippi Medical Center, Jackson, Mississippi, USA.
Insights
The revised pediatric heart allocation policy increased ventricular assist device (VAD) use and heart transplant rates. While waitlist times changed differently for congenital heart disease (CHD) and non-CHD patients, 90-day survival improved for CHD patients.
Area of Science:
- Pediatric Cardiology
- Transplant Surgery
- Health Policy Analysis
Background:
- The pediatric heart allocation policy was revised to optimize outcomes for children awaiting heart transplantation.
- Understanding the impact of policy changes on ventricular assist device (VAD) utilization and survival is crucial.
Purpose of the Study:
- To analyze the effects of the revised pediatric heart allocation policy on VAD use, waitlist (WL), and post-heart transplant (HT) survival.
- To compare outcomes between congenital heart disease (CHD) and non-CHD pediatric patients before and after policy implementation.
Main Methods:
- Retrospective review of the UNOS database (December 2011 - March 2021) for pediatric patients (<18 years) listed for primary HT.
- Comparison of patient characteristics, VAD utilization, WL duration, and survival outcomes between pre-policy (Era-1) and post-policy (Era-2) periods.
Main Results:
- VAD utilization (temporary and durable) and heart transplantation rates increased post-policy.
- Waitlist duration increased for CHD patients but decreased for non-CHD patients.
- Adjusted 90-day waitlist survival improved significantly for CHD patients (84% to 88%) but not for non-CHD patients.
Conclusions:
- The revised policy led to increased VAD support and heart transplant rates.
- Improved 90-day waitlist survival was observed in children with CHD, with no significant change in 1-year post-HT survival for either group.
- Further policy refinement may be needed to optimize waitlist duration and post-transplant outcomes.
Aims:
We analyzed the impact of the revised pediatric heart allocation policy on types of ventricular assist device (VAD) utilization, and waitlist (WL) and post-heart transplant (HT) survival outcomes in congenital heart disease (CHD) versus non-CHD patients before (Era-1) and after (Era-2) pediatric heart allocation policy implementation.
Methods:
We retrospectively reviewed the UNOS database from December 16, 2011, through March 31, 2021, for patients < 18 years old and listed for primary HT. We compared the differences observed between Era-1 and Era-2.
Results:
5551 patients were listed for HT, of whom 2447(44%) were in Era-1 and 3104(56%) were in Era-2. CHD patients were listed as status 1A unchanged, but the number of patients listed as status 1B decreased in Era-2, whereas the number of non-CHD patients listed as status 1A decreased, but status 1B increased. In Era-2 compared to Era-1, both temporary (1% to 4%, p < .001) and durable VAD (13.6% to 17.8%, p < .001) utilization increased, and the transplantation rate per 100-patient years increased in both groups. The median WL period for CHD patients increased marginally from 70 to 71 days (p = .06), whereas for non-CHD patients it decreased from 61 to 54 days (p < .001). Adjusted 90-day WL survival increased from 84% to 88%, p = .016 in CHD, but there was no significant change in non-CHD patients (p = .57). There was no significant difference in 1-year post-HT survival in CHD and non-CHD patients between Era-1 and Era-2.
Conclusions:
In summary, after the revised heart allocation policy implementation, temporary and durable VAD support increased, HT rate increased, waitlist duration marginally increased in the CHD cohort and decreased in the non-CHD cohort, and 90-day WL survival probability improved in children with CHD without significant change in 1-year post-HT outcomes. Future studies are needed to identify changes to the policy that may further improve the listing criteria to improve WL duration and post-HT survival.
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