Evolving Trends and Widening Racial Disparities in Children Listed for Heart Transplantation in the United States
2022; Lippincott Williams & Wilkins; Volume: 146; Issue: 3 Linguagem: Inglês
10.1161/circulationaha.122.060223
ISSN1524-4539
AutoresM. Mujeeb Zubair, Qiudong Chen, Georgina Rowe, George Gill, J. Thomas, Shrishiv A. Timbalia, Asishana A. Osho, Michael E. Bowdish, Vikram Sood, Kurt R. Schumacher, Joanna Chikwe, Richard W. Kim,
Tópico(s)Organ Transplantation Techniques and Outcomes
ResumoHomeCirculationVol. 146, No. 3Evolving Trends and Widening Racial Disparities in Children Listed for Heart Transplantation in the United States Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEvolving Trends and Widening Racial Disparities in Children Listed for Heart Transplantation in the United States M. Mujeeb Zubair, MD, Qiudong Chen, MD, Georgina Rowe, MD, George Gill, MD, Jason Thomas, BS, Shrishiv A. Timbalia, MD, Asishana A. Osho, MD, MPH, Michael E. Bowdish, MD, Vikram Sood, MD, Kurt R. Schumacher, MD, MS, Joanna Chikwe, MD and Richard W. Kim, MD M. Mujeeb ZubairM. Mujeeb Zubair Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). , Qiudong ChenQiudong Chen Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). , Georgina RoweGeorgina Rowe Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). , George GillGeorge Gill https://orcid.org/0000-0001-6673-5841 Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). , Jason ThomasJason Thomas Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). , Shrishiv A. TimbaliaShrishiv A. Timbalia Department of Vascular Surgery, Houston Methodist Hospital, Houston, TX (S.A.T.). , Asishana A. OshoAsishana A. Osho Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA (A.A.O.). , Michael E. BowdishMichael E. Bowdish https://orcid.org/0000-0002-0863-2825 Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). , Vikram SoodVikram Sood University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, Ann Arbor, MI (V.S., K.R.S.). , Kurt R. SchumacherKurt R. Schumacher https://orcid.org/0000-0001-8659-736X University of Michigan Congenital Heart Center, C. S. Mott Children's Hospital, Ann Arbor, MI (V.S., K.R.S.). , Joanna ChikweJoanna Chikwe Correspondence to: Joanna Chikwe, MD, Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, Pavilion, Suite A3100, Los Angeles, CA 90048. Email E-mail Address: [email protected] https://orcid.org/0000-0002-6206-4259 Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). and Richard W. KimRichard W. Kim Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.Z., Q.C., G.R., G.G., J.T., A.A.O., M.E.B., J.C., R.W.K.). Originally published18 Jul 2022https://doi.org/10.1161/CIRCULATIONAHA.122.060223Circulation. 2022;146:262–264To reduce waitlist mortality among children listed for heart transplantation, the Organ Procurement and Transplantation Network revised pediatric heart allocation criteria in 2016 by prioritizing patients on inotropic support with a primary diagnosis of congenital heart disease (CHD) over other cardiomyopathies.1 Given that CHD is more common in White than in non-White children, it is hypothesized that the new allocation system might negatively affect transplant opportunity in non-White children.2–4 The publicly available United Network for Organ Sharing database was therefore analyzed to evaluate evolving trends in pediatric heart transplant candidates listed between December 2011 and December 2020, with a focus on racial disparities. Waitlist mortality was analyzed with transplantation or recovery as a competing risk. Children listed before the allocation changes (before March 22, 2016) who remained on the waitlist afterward (n=310) were censored to avoid confounding. Children are listed for transplantation as status 1A (highest priority), status 1B, or status 2 on the basis of criteria used to assess medical urgency.1 Exceptions can also be made to grant a higher listing status on the basis of perceived waitlist mortality risk and potential transplantation benefit. Data supporting these findings are available on request to United Network for Organ Sharing at https://optn.transplant.hrsa.gov/data/request-data/ and the analytical methods are available from the corresponding author on reasonable request. This study was approved by the institutional review board of Cedars-Sinai Medical Center.After excluding patients with multiorgan listing (n=225), 2460 and 3501 children were listed before and after the policy change, respectively. Median waitlist time was 72 (interquartile range [IQR], 27–176) days. The proportion of children listed under status 1A decreased after the policy change (71.9% versus 59.1%, P<0.001). The proportion of status 1A children with CHD increased (45.8% versus 59.9%, P<0.001) and those with cardiomyopathy decreased (46.6% versus 32.5%, P<0.001). The cumulative incidence of 1-year waitlist mortality was 11.1% (95% CI, 9.8–12.4) before the policy change and 9.1% (95% CI, 8.1–10.1) afterward (P=0.02). There was a significant decrease in waitlist mortality after the policy change in the overall cohort, all CHD patients, and status 1A patients with CHD (Figure A–C). Waitlist mortality among patients with cardiomyopathy was unchanged (Figure D). One-year after transplant survival was 93.1% (95% CI, 91.5–94.3) before the policy change and 92.8% (95% CI, 91.4–94.0) afterward (P=0.75).Download figureDownload PowerPointFigure 1. Cumulative incidence of waitlist mortality before (dashed line) and after (solid line) the 2016 pediatric heart allocation policy change. A, All listed waitlist candidates. B, Congenital heart disease candidates. C, Congenital heart disease candidates listed as status 1A. D, Cardiomyopathy candidates. E, White children with congenital heart disease. F, Non-White children with congenital heart disease. All hazard ratios shown are unadjusted unless specified. CHD indicates congenital heart disease; CM, cardiomyopathy; and sHR, subdistribution hazard ratio.CHD was more common in White than non-White children both before (52.3% versus 41.6%) and after (55.6% versus 48.3%) the policy change (both P<0.001), although an increased proportion of listed non-White children had CHD after the policy change (P<0.001). Median waitlist time increased from 64 (IQR, 25–146) to 79 (IQR, 31–211) days in non-White children and from 66 (IQR, 24–147) to 76 (IQR, 28–197) days in White children (both P<0.001), and waitlist times were similar between groups before and after the policy change (P=0.89 and P=0.27, respectively). After the policy change, the proportion of patients with CHD in status 1A decreased from 71.0% to 65.4% in White children (P<0.001) but increased from 67.6% to 71.2% (P=0.003) in non-White children. Non-White children were more likely to have public insurance both before and after the policy change (70.7% versus 38.5% and 71.6% versus 41.6%, respectively, both P<0.001). An increase in status 1A exception use under the new policy was seen in both White (6.8%–14.6%, P<0.001) and non-White children (6.5%–16.5%, P<0.001), with no difference in the prevalence of its use between groups (14.6% versus 16.5%, P=0.16). The use of a ventricular assist device increased after the policy change in both White children (8.9%–14.9%, P<0.001) and non-White children (11.7%–15.9%, P=0.002), and a similar proportion of children in each group was listed with a ventricular assist device under the new policy (P=0.45).In the unadjusted analysis, implementation of the new allocation system was associated with significantly improved waitlist mortality in White children only (hazard ratio, 0.68 [95% CI, 0.53–0.86]). In the multivariable analysis limited to patients with CHD adjusting for listing status and other baseline risk factors (insurance type, before transplant extracorporeal membrane oxygenation, before transplant mechanical ventilation, dialysis before transplant, recipient weight, and retransplantation), the new system was associated with a reduced waitlist mortality in White children (adjusted hazard ratio, 0.70 [95% CI, 0.52–0.94]) but not in non-White children (adjusted hazard ratio, 0.95 [95% CI, 0.67-1.34]; Figure E and F). These effects were not observed in children with cardiomyopathy.Study limitations include the lack of data capturing changes in clinical and listing status while on the waitlist. Important confounders may include social determinants of health, changes in the management of patients with CHD, and practice variation in recipient and donor selection criteria.In summary, the 2016 pediatric heart allocation policy revisions successfully improved waitlist mortality in children with CHD, without affecting 1-year after transplant survival. This finding was consistent with a recent analysis evaluating waitlist trends in patients with CHD.4 However, these policy revisions were only associated with reduced waitlist mortality in White children with CHD, and non-White children with CHD had a waitlist mortality similar to the old allocation system. This suggests health care inequities in children with CHD that warrant targeted assessment to uncover the contributing mechanisms.Article InformationSources of FundingThis work was supported in part by Health Resources and Services Administration contract 234-2005-370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. Dr Chen is supported by a grant from the National Institutes of Health for advanced heart disease research (T32HL116273).Nonstandard Abbreviations and AcronymsCHDcongenital heart diseaseIQRinterquartile rangeDisclosures None.FootnotesCirculation is available at www.ahajournals.org/journal/circFor Sources of Funding and Disclosures, see page 264.Correspondence to: Joanna Chikwe, MD, Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, Pavilion, Suite A3100, Los Angeles, CA 90048. Email joanna.[email protected]orgReferences1. Alcorn JB. Changes to OPTN bylaws and policies from actions at June Board of Directors meeting.Accessed November 30, 2021. https://optn.transplant.hrsa.gov/media/1822/optn_policy_notice_07-24-2014.pdfGoogle Scholar2. Magnetta DA, Godown J, West S, Zinn M, Rose-Felker K, Miller S, Feingold B. Impact of the 2016 revision of US Pediatric Heart Allocation Policy on waitlist characteristics and outcomesAm J Transplant. 2019; 19:3276–3283. doi: 10.1111/ajt.15567CrossrefMedlineGoogle Scholar3. Amdani S, Bhimani SA, Boyle G, Liu W, Worley S, Saarel E, Hsich E. Racial and ethnic disparities persist in the current era of pediatric heart transplantationJ Card Fail. 2021; 27:957–964. doi: 10.1016/j.cardfail.2021.05.027CrossrefMedlineGoogle Scholar4. Townsend M, Karamlou T, Boyle G, Daly K, Deshpande S, Auerbach SR, Worley S, Liu W, Saarel E, Amdani S. Waitlist outcomes for children with congenital heart disease: lessons learned from over 5000 heart transplant listings in the United States [published online March 14, 2022].J Card Fail. doi: 10.1016/j.cardfail.2022.03.004Google Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByCarnethon M, Rodriguez F and Watson K (2022) Toward a Broader Conceptualization of Disparities and Solutions, Circulation, 146:3, (145-146), Online publication date: 19-Jul-2022. July 19, 2022Vol 146, Issue 3 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.060223PMID: 35861769 Originally publishedJuly 18, 2022 Keywordsheart transplantationwaiting listshealth status disparitiesPDF download Advertisement SubjectsCongenital Heart DiseaseDisparitiesTransplantation
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