The Organ Procurement and Transplantation Network (OPTN) implemented a new donor heart allocation policy on October 18, 2018.Studies evaluating the impact of this new policy on posttransplant survival contain discrepant findings. 1 Five reports found decreased posttransplant survival under the new policy, 2-6 and two reports found no difference in posttransplant survival. 7,8 Notably, the studies with lower estimates of posttransplant survival in the post-policy era have significantly fewer follow-up observations of post-policy recipients compared with the studies finding unchanged survival. One proposed explanation for the conflicting results is informative censoring bias. 9 A fundamental assumption of the Kaplan-Meier survival estimator is that censoring is statistically independent of
Under the new US heart allocation policy, transplant centers listed significantly more candidates at high priority statuses (Status 1 and 2) with mechanical circulatory support devices than expected. We determined whether the practice change was widespread or concentrated among certain transplant centers. Using data from the Scientific Registry of Transplant Recipients, we used mixed-effect logistic regression to compare the observed listings of adult, heart-alone transplant candidates postpolicy (December 2018 to February 2020) to seasonally matched pre-policy cohort (December 2016 to February 2018). US transplant centers (N = 96) listed similar number of candidates in each policy period (4472 vs. 4498) but listed significantly more at high priority status (25.5% vs. 7.0%, p < .001) than expected. Adjusted for candidate characteristics, 91 of 96 (94.8%) centers listed significantly more candidates at highpriority status than expected, with the unexpected increase varying from 4.8% to 50.4% (interquartile range [IQR]: 14.0%-23.3%). Centers in OPOs with highest Status 1A transplant rate pre-policy were significantly more likely to utilize high-priority status under the new policy (OR: 9.73, p = .01). The new heart allocation policy was associated with widespread and significantly variable changes in transplant center practice that may undermine the effectiveness of the new system.
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