Status 1 Listing Post Allocation Change: Center Level Variation in Exception Use and Ongoing Disparities Limit Equitable Access to Transplant

Document Type

Conference Proceeding

Publication Date

4-1-2025

Publication Title

J Heart Lung Transplant

Abstract

Purpose: We sought to 1) assess overall trends and center-level heterogeneity in status 1 (highest acuity) heart transplant (HT) listing in the US 2) identify subgroups of status 1 candidates with inequitable outcomes. Methods: Adult waitlist candidates listed for a first time, single organ HT as status 1 in OPTN between 10/2018 until 9/15/2023 were included. Trends in status 1 listing and the proportion of status 1 exception (1E) by center size were plotted. Wait list outcomes by blood group, sex, race, diagnosis type, and exception use were investigated using Fine Gray competing risk analyses. Results: The study cohort consisted of 2,296 candidates who were listed for HT as a Status 1. Status 1 use increased over time (7.0 % in 2018 vs.12.8 % 2023, p < 0.001), including increased in Status1E listing (3.3% - 7.7%, p < 0.001). There was wide variation in exception use by center (5 % to 100 %, Figure). Compared to Status 1 candidates, those listed by exception had a lower rate of delisting for death or deterioration (HR 0.58, 95% CI 0.41 to 0.8, p < 0.001) but a similar at 30 days cumulative incidence of HT. Among status 1 waitlist candidates, disparities in access to transplant were observed for women, blood group O, and Black populations, which persisted after multivariable adjustment (Table). Blood group O (8.5 %) and congenital heart disease (9.5 %) patients suffered the highest rates of delisting for death or clinical deterioration at 30 days compared to other groups (restrictive 3.3% and ischemic 2.8%). Conclusion: Status 1 use has increased over time and wide variation in Status 1 E listing patterns exist by center. Ongoing disparities exist among multiple underserved populations of high acuity patients. These findings suggest that goal of equitable access to HT is not currently being achieved among the highest acuity patients. Monitoring center-level variation in care and including these identified factors in continuous allocation could reduce disparities and promote equitable access. [Formula presented]

Volume

44

Issue

4

First Page

S30

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