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Am Heart J Plus
Am Heart J Plus
American Heart Journal Plus: Cardiology Research and Practice
2666-6022
Elsevier

S2666-6022(24)00089-2
10.1016/j.ahjo.2024.100446
100446
Research Letter
Assessing racial disparities in heart transplant allocations post-2018 policy change
Malkani Kabir ycs9004@nyp.org
a⁎
Zhang Ruina b
Kini Vinay a
a Weill Cornell Medicine, Department of Medicine, Division on Cardiology, 520 East 70th Street, Starr 4, New York, NY 10021, United States of America
b New York University Langone Health, Department of Medicine, Division of Cardiology, 550 First Avenue, New York 10016, United States of America
⁎ Corresponding author at: Weill Cornell Medicine, Department of Medicine, Division of Cardiology, 520 East 70th Street, Starr 4, New York, NY 10021, United States of America. ycs9004@nyp.org
24 8 2024
9 2024
24 8 2024
45 1004461 8 2024
20 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords

Racial disparities
Heart transplant
Disparities
Transplant
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pmcHeart failure (HF) is a major public health issue in the U.S., currently affecting 6.2 million patients [1]. Heart transplant is recommended for some patients with advanced HF, but prior studies have shown race disparities in access. The 2018 allocation policy update aimed to improve equitable access by implementing objective physiological criteria and revising the geographic distribution of donor hearts to decrease waitlist mortality [2,3]. Our study investigates whether racial inequalities have persisted after the 2018 policy using data from the Organ Procurement and Transplantation Network (OPTN).

We analyzed 2023 OPTN transplant data and the active OPTN waitlist data (March 2024 at the time of analysis) to evaluate the equity of transplantation against the demographics of the waitlist. We computed a relative waitlist-to-transplant ratio for Black patients compared to White patients in 2023, calculated as follows:Black patientsonWaitlistBlack patientsonWaitlist+Black patients transplanted in2023White patientsonWaitlistWhite patientsonWaitlist+White patients transplanted in2023

A ratio greater than 1 suggests underrepresentation of Black patients in receiving transplants compared to White patients.

We identified 4545 patients who were transplanted in 2023 (70.6 % male, 24.8 % black) and another 3437 who were actively on the waitlist (76.1 % male, 28.2 % black). Nationally, the waitlist-to-transplant ratio for Black compared to White patients was 1.11 (95 % CI: 1.05–1.18; ratios for individual UNOS regions are provided in supplementary figure 1). The most significant disparities were seen in some of the Northeastern regions of the United States; 1.31 (95 % CI: 1.09–1.56) in Region 2 and 1.22 (95 % CI: 1.02–1.47) in Region 9.

Previous studies have established that social and economic factors lead to worse post-cardiac transplant outcomes for Black patients, and contribute to disparities in initial heart transplant listings [2,4]. In line with these findings, our research suggests that Black patients are also disproportionately underrepresented in heart transplant recipients relative to their listing numbers. These disparities were seen before the 2018 allocation policy as well, as White patients were transplanted at a small but significantly higher rate than black patients [5]. Our results suggest that despite changes to the allocation policy in 2018, racial disparities persist. Wealthier patients, often White, can afford to be listed at multiple sites, increasing their transplant chances. Lower donor registration rates among Black Americans also reduce organ match opportunities due to human leukocyte antigen matching [6].

Recent studies indicate unconscious biases affect transplant offers and acceptance rates for Black patients, with an odds ratio of 0.76 for the first offer acceptance compared to White candidates. Another study found that black patients are perceived as sicker, and concerns about trust and adherence affect their likelihood of being offered a transplant [7,8]. Provider education on reducing unconscious biases may help address these disparities. Limitations of this study include lack of data on socioeconomic status, healthcare access, comorbid conditions, and the impact of multiple listings. Our findings suggest that ongoing efforts are needed to eliminate racial disparities and move closer to a more equitable transplant system.

Disclosure statement

None of the authors have anything to disclose.

Ethical statement

This manuscript is the authors' original work, which has not been published elsewhere and is not currently being considered for publication elsewhere.

All authors have made substantial contributions to the conception of the study, the acquisition, analysis, and interpretation of data, drafting and revising the manuscript, and have given final approval of the version to be submitted.

CRediT authorship contribution statement

Kabir Malkani: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. Ruina Zhang: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing. Vinay Kini: Supervision, Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following is the supplementary data related to this article.Supplementary Fig. 1

Map showing the distribution of the 11 different UNOS regions. B: The waitlist-to-transplant ratio nationally and for each region, with 95% confidence intervals included.

Supplementary Fig. 1

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.ahjo.2024.100446.
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