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Waitlist and post-transplant outcomes in rural communities with the current heart transplant allocation
Mohammad U Ahmed1,2, Michael Dickinson1,2, David Fermin1,2
1Corewell Health Frederik Meijer Heart and Vascular Institute, Grand Rapids, MI.
Insights
The 2018 heart transplant policy improved waitlist outcomes, but rural residents face higher death/delisting rates post-allocation. Transplantation rates and survival remain similar for rural and urban patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Services Research
Background:
- The 2018 Organ Procurement and Transplantation Network (OPTN) heart transplant allocation policy aimed to improve waitlist outcomes.
- Despite policy improvements, persistent disparities in heart transplantation (HT) access and outcomes between rural and urban populations warrant investigation.
Purpose of the Study:
- To evaluate the impact of the 2018 OPTN heart transplant allocation policy on waitlist and post-transplantation outcomes in rural versus urban communities.
- To identify potential disparities in heart transplant outcomes based on geographic residence.
Main Methods:
- Analysis of 26,450 patients listed for HT between 2014 and 2021 from the OPTN database.
- Classification of patients as rural or urban based on ZIP code.
- Calculation of cumulative incidence (CI) of death/delisting and transplantation, and post-transplant survival using Kaplan-Meier methods.
Main Results:
- Both rural and urban communities experienced decreased waitlist death/delisting and increased HT rates under the new policy.
- In the current allocation, rural residents showed a higher adjusted frequency of death/delisting (p=0.01) compared to urban residents.
- No significant differences were observed in HT cumulative incidence or post-transplant survival between rural and urban groups.
Conclusions:
- While the 2018 policy reduced waitlist mortality overall, rural residence is linked to a disproportionately higher risk of death/delisting.
- No disparities in transplant rates or survival post-transplantation were found based on rural or urban status.
Background:
The OPTN heart transplant allocation policy implemented in 2018 led to significant improvements in waitlist outcomes, but disparities persist. Our study evaluated the effect of the implementation of the new allocation on waitlist and post-transplantation outcomes in rural versus urban communities.
Methods:
Patients registered for HT in the OPTN database between January 1, 2014, and December 31, 2021, were included as rural or urban according to ZIP code. The cumulative incidence (CI) of death/delisting and transplantation in the different allocations were calculated. Post-transplant survival was calculated using Kaplan-Meier methodology.
Results:
26,450 patients were listed for transplant. Rural residents were more commonly white and had a higher incidence of ischemic cardiomyopathy. Both allocations saw a similar decrease in the CI of death/delisting from the wait list and an increase in the CI of HT in both rural and urban communities. In the prior allocation, no differences existed in the CI of death/delisting or transplantation between rural and urban residents. In the current allocation, rural residents had a higher frequency of death/delisting (p=0.01) after adjusting for risk factors. No differences existed in the CI of transplantation or post-transplant survival.
Conslusions:
Our findings suggest that despite an overall decrease in CI of death/delisting in both rural and urban communities, rural residence is associated with a disproportionately higher CI of death/delisting on the transplant list in the current allocation. We found no differences in the CI of transplantation or survival after transplant.
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