Psychosocial Risk Assessment for Heart Transplantation: Evaluating for Bias and Impact on Post-transplant Outcomes

Pretransplant psychosocial risk (PSR) assessment is subjective, so we investigated potential biases and the relationship between assessed PSR and post-transplant outcomes at our heart transplant center.

Between 05/2004 and 01/2021, 479 heart transplant (HT) recipients had a pre-transplant psychosocial evaluation, at which a social worker collected information about 25 characteristics and categorized the candidate's PSR for post-transplant death. Relationships between PSR and post-transplant outcomes (death, hospitalization and rejection) were evaluated. Possible biases in PSR evaluation were examined by assessing the independent relationships among race, sex, psychosocial characteristics, additional socioeconomic characteristics imputed from U.S. census data, and the PSR categorization.

Psychosocial risk was categorized as low (399), medium (57) or high (23). Medium- or high-risk patients were younger and more likely to have psychosocial risk factors and live in less affluent neighborhoods. Race and sex were not found to influence the PSR categorization (both P = 0.4). Neighborhood affluence score (OR 0.30; P = 0.009) and family/social support (OR 500; P < 0.001) were strongly and independently associated with PSR categorization; less affluent patients and those without family/social support were more likely to be classified as being at medium or high risk. Medium- or high-risk categorization was not associated with increased mortality or hospitalization rates after HT (P = 0.5 and 0.3, respectively), but it was associated with increased risk for experiencing rejection (HR 1.7, CI 1.02-2.90).

Medium or high PSR was associated with a greater risk of rejection but not of hospitalization or death. There was no indication of race or sex bias in our program's preoperative psychosocial evaluations, but patients' affluence may have influenced decision making.