Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Breathett, Khadijah; Knapp, Shannon M.; Lewsey, Sabra C.; Mohammed, Selma F.; Mazimba, Sula; Dunlay, Shannon M.; Hicks, Albert; Ilonze, Onyedika J.; Morris, Alanna A.; Tedford, Ryan J.; Colvin, Monica M.; Daly, Richard C.

doi:10.1001/jama.2024.0065

JAMA

2024

DOI: 10.1001/jama.2024.0065

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Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Khadijah Breathett,

Shannon M. Knapp,

Sabra C. Lewsey

et al.

Abstract: ImportanceBarriers to heart transplant must be overcome prior to listing. It is unclear why Black men and women remain less likely to receive a heart transplant after listing than White men and women.ObjectiveTo evaluate whether race or gender of a heart transplant candidate (ie, patient on the transplant waiting list) is associated with the probability of a donor heart being accepted by the transplant center team with each offer.Design, Setting, and ParticipantsThis cohort study used the United Network for Or… Show more

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Cited by 8 publications

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Is Equity Being Traded for Access to Heart Transplant?

Heidenreich,

Lewis,

Khush

2024

JAMA

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Disparities in care and outcomes are common, complex problems and are well illustrated by heart failure, from the initial diagnosis to the treatment of advanced disease. In the US, Black individuals develop heart failure at a much younger age than individuals of other races, and the incidence for Black individuals is 50% higher than that for White individuals. 1 Although the age-adjusted hospitalization rate for Black patients with heart failure in the US has decreased over the past 20 years, it was still approximately 2.2 times the rate for White patients in 2018. 2 There is also a concern for disparities in unrecognized heart failure among Black patients and among female patients, as they are more likely to be diagnosed in the acute care setting despite having symptoms for months before diagnosis. 3 The increased risk extends to those with end-stage heart failure, with Black patients accounting for 26.5% of hospitalizations coded as end-stage heart failure (2017-2020), 4 which is double their 12.1% share of the overall US population in the 2020 US census.The optimal treatment of end-stage heart failure is heart transplant, and the first step is to be placed on the transplant waiting list. In 1987, only 7% of those listed for transplant were self-identified as Black, but this number rose to 25% in 2019. 5 Once listed, priority status is assigned based on standard criteria, although listing priority can be changed if the transplant team requests and is granted an exception. 6 Despite the high cost and limited number of available donor organs, the total number of heart transplants has continued to improve for all groups, with 26% of heart transplants occurring in Black patients in 2019, up from 5% of all heart transplants in 1987. 5 However, worrisome racial and ethnic differences persist. Among those listed from 2011 to 2020, Asian patients had the greatest probability of receiving a transplant (adjusted hazard ratio [AHR], 1.38; 95% CI, 1.28-1.48) followed by Hispanic patients (AHR, 1.04; 95% CI, 0.99-1.09) and then Black patients (AHR, 0.87; 95% CI, 0.84-0.90), all compared with White patients. 7 The difference in transplant rate between Black and White patients appears to be decreasing over time. 5 Moreover, there is evidence of fewer heart transplant listings for female patients. From 2011 to 2021, the percentage of wait-listed female patients decreased from 26% to 24%, 8 while the percentage of hospitalizations coded for end-stage heart failure in women was 29% (2017-2020). 3 Concomitantly (2011-2021), the percentage of transplant recipients who were female decreased from 28% to 26%. 8 Overall, however, women have a higher rate of transplant, with 120 transplants per 100 patient-years on the waiting list compared with 100 transplants per 100 patient-years for men. 8

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Is Equity Being Traded for Access to Heart Transplant?

Heidenreich,

Lewis,

Khush

2024

JAMA

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Race, Gender, and Donor Heart Acceptance

Majeed,

Cecere

2024

JAMA

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To the Editor Cardiac transplant is a lengthy process informed by social determinants of health and race-based differences. A recent study 1 revealed that Black candidates had lower cumulative incidence of heart offer acceptance by transplant center teams compared with White candidates, and offer acceptance was higher for women than for men. 1 The authors used the United Network for Organ Sharing datasets and included adults listed for heart transplant from 2018 to 2023. 1 This period included the COVID-19 pandemic, during which time transplant programs had resource challenges. 2 Moreover, many centers in the US reserved active status on the transplant waiting list only for patients with high waitlist mortality and illness severity during the COVID-19 pandemic. 3 A study of 22 997 patients reported that young Black recipients had a high risk of mortality in the first year after transplant, which may have been attributed to more severe illness and comorbidity prior to cardiac transplant. 4 Hence, we question how the COVID-19 pandemic influenced equitable heart transplant after listing.Furthermore, we would like to know why the authors of this study 1 did not consider geographical variation when explaining their findings. A study that used data from the United Network for Organ Sharing database reported that transplant centers with the most active waitlists had lower waitlist mortality. 5 Although this study assessed waitlist mortality and cardiac transplant outcomes, it highlighted the substantial differences in transplant performance among states across the US. We therefore are curious to know if some transplant team centers located in certain parts of the US had differential race and gender disparities in heart transplant allocation.

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Race, Gender, and Donor Heart Acceptance—Reply

Breathett,

Knapp

2024

JAMA

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COMMENT & RESPONSEIn Reply Ms Majeed and colleagues pose important questions regarding our study. 1 First, the COVID-19 pandemic had several possible implications for transplant care. To explore these implications, we reexamined the number of donor heart offers until acceptance as in the original article 1 but censored observations after February 29, 2020, to exclude the COVID-19 period. For both analyses, we maintained the start date of October 18, 2018, because the United Network for Organ Sharing changed heart transplant listing criteria on this date. The pattern was consistent with our original findings, 1 with the median number of offers until acceptance lowest for White women (5; 95% CI, 4-5), followed by Black women (6; 95% CI, 5-7), White men (8; 95% CI, 7-8), and Black men (9; 95% CI, 8-10) (log-rank P < .001) (Figure). These findings suggest that these race and gender disparities in acceptance of heart donors by transplant centers predated the COVID-19 pandemic and persisted during COVID-19.Second, it is important to note that in our initial study and in this analysis, we included only donors who were ultimately accepted, representing "good hearts." As programs reevaluate their donor acceptance patterns, we recommend focusing on the donor matches that were ultimately accepted by another transplant program and considering whether patient race and gender were associated with donor acceptance at the program level. We are investigating geographical and center-level characteristics that may be associated with the decision to accept a matched donor heart according to patient race and gender. These findings will be published separately on completion.Multiple decisions must be aligned for patients to receive a timely heart transplant and have optimal survival. Often patient characteristics such as race, ethnicity, and gender unjustly contribute to the health care professional decision matrix, particularly for Black patients. 2,3 Implementation science strategies should be prioritized to achieve equity in identification and delivery of appropriate care in heart transplant. 4

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Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List

Cited by 8 publications

References 28 publications

Is Equity Being Traded for Access to Heart Transplant?

Is Equity Being Traded for Access to Heart Transplant?

Race, Gender, and Donor Heart Acceptance

Race, Gender, and Donor Heart Acceptance—Reply

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