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Disparities in Listing With a Durable Left Ventricular Assist Device After 2018 Heart Allocation Policy Change
Alexander Z Wang1, Molly H White2, Nikhil Narang3
1Department of Medicine, University of Southern California, Los Angeles, California, USA.
Insights
After the 2018 heart policy change, vulnerable patients were more likely to receive a durable left ventricular assist device (LVAD) bridge-to-transplant. This may worsen transplant disparities, requiring policy changes for equitable heart allocation.
Area of Science:
- Cardiology
- Transplant Surgery
- Health Equity
Background:
- The 2018 U.S. heart allocation policy shift reduced the use of bridge-to-transplant (BTT) durable left ventricular assist device (LVAD) strategies.
- Previous research indicates patients with BTT LVADs face lower transplant rates under the current policy.
- Candidates from vulnerable communities experience reduced transplant rates post-listing.
Purpose of the Study:
- To investigate if the 2018 policy change disproportionately affected the listing of vulnerable patients with BTT LVADs.
- To analyze the impact of neighborhood deprivation on BTT LVAD listing post-policy change.
Main Methods:
- Utilized data from the Scientific Registry of Transplant Recipients (SRTR) for adult heart transplant candidates listed between 2014-2024.
- Divided candidates into prepolicy and postpolicy cohorts based on the October 18, 2018 policy change.
- Employed mixed-effects logistic regression to assess the association between Area Deprivation Index (ADI) and BTT LVAD listing, adjusting for candidate and center characteristics.
Main Results:
- The study included 43,342 candidates; BTT LVAD use decreased from 25% prepolicy to 18% postpolicy.
- The interaction between ADI and policy period significantly impacted BTT LVAD listing odds (P < 0.001).
- Postpolicy, candidates in the most deprived areas (10th ADI decile) had 59% higher odds of BTT LVAD listing compared to the least deprived (1st decile).
Conclusions:
- The 2018 policy change led to increased BTT LVAD listing likelihood in vulnerable populations.
- This practice may exacerbate existing disparities in heart transplant access.
- Policy adjustments are necessary to promote equity in BTT LVAD listing and heart allocation.
Background:
Following the 2018 U.S. heart allocation policy change, transplant centers became less likely to use a bridge-to-transplant (BTT) durable left ventricular assist device (LVAD) strategy. Previous work has shown that patients with BTT LVADs are less likely to be transplanted under this current allocation policy. Candidates from vulnerable communities also have lower transplant rates after listing.
Objectives:
The authors sought to determine if listing with BTT-LVADs disproportionately changed in vulnerable communities after the 2018 policy change.
Methods:
This study used data from the SRTR (Scientific Registry of Transplant Recipients). The study cohort included adult heart transplant candidates initially listed between 2014 and 2024, divided into prepolicy and postpolicy cohorts (before or after October 18, 2018). The primary exposure was neighborhood deprivation, measured by the national ADI (Area Deprivation Index) of the candidate's place of residence. The association of the interaction of ADI and policy period and the odds of a candidate being listed with a BTT-LVAD were estimated using a mixed-effects logistic regression model with a random intercept based on the listing center, adjusted for center characteristics and candidate characteristics.
Results:
The final study cohort included 43,342 candidates (17,655 prepolicy candidates and 25,687 postpolicy candidates). During the prepolicy period, 4,440 (25%) candidates were listed with a BTT-LVAD, compared to 4,658 (18%) under the current policy (P < 0.001). In our fully adjusted model, the impact of the candidate ADI on the likelihood of a candidate being listed with a BTT-LVAD differed significantly between policy periods (P < 0.001). In the prepolicy period, the ADI was not associated with odds of listing with a BTT-LVAD (prepolicy OR: 1.00 [95% CI: 0.98-1.02]; P > 0.9). In the postpolicy period, candidates in the 10th ADI decile (most disadvantage) had 59% higher odds of listing with a BTT-LVAD than first-decile candidates (postpolicy OR: 1.05 [95% CI: 1.03-1.08]; P < 0.001).
Conclusions:
After the 2018 heart allocation policy change, candidates from more vulnerable communities became more likely to be listed with a BTT-LVAD. This change in practice may exacerbate place-based disparities in heart transplant access. Policy changes are needed to ensure greater equity among candidates being listed with a BTT-LVAD and heart allocation.
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