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Association of Transplant Center With Survival Benefit Among Adults Undergoing Heart Transplant in the United States

Educational Objective
To learn how candidates for heart transplant are selected in the United States.
1 Credit CME
Key Points

Question  Is there an association between transplant center and the survival benefit associated with heart transplant in the United States?

Findings  In this registry-based observational study of 29 199 candidates for heart transplant in the United States, the 5-year survival benefit associated with heart transplant ranged from 30% to 55%. Estimated waiting list survival without transplant was significantly lower at centers with survival benefits significantly above the mean compared with those below the mean (29% at high survival benefit centers vs 39% at low survival benefit centers), but there was no significant difference in survival after the transplant (77.6% vs 77.1%, respectively).

Meaning  The 5-year survival benefit associated with heart transplant varied across transplant centers, and high survival benefit centers performed heart transplant for patients with lower estimated waiting list survival without transplant.

Abstract

Importance  In the United States, the number of deceased donor hearts available for transplant is limited. As a proxy for medical urgency, the US heart allocation system ranks heart transplant candidates largely according to the supportive therapy prescribed by transplant centers.

Objective  To determine if there is a significant association between transplant center and survival benefit in the US heart allocation system.

Design, Setting, and Participants  Observational study of 29 199 adult candidates for heart transplant listed on the national transplant registry from January 2006 through December 2015 with follow-up complete through August 2018.

Exposures  Transplant center.

Main Outcomes and Measures  The survival benefit associated with heart transplant as defined by the difference between survival after heart transplant and waiting list survival without transplant at 5 years. Each transplant center’s mean survival benefit was estimated using a mixed-effects proportional hazards model with transplant as a time-dependent covariate, adjusted for year of transplant, donor quality, ischemic time, and candidate status.

Results  Of 29 199 candidates (mean age, 52 years; 26% women) on the transplant waiting list at 113 centers, 19 815 (68%) underwent heart transplant. Among heart transplant recipients, 5389 (27%) died or underwent another transplant operation during the study period. Of the 9384 candidates who did not undergo heart transplant, 5669 (60%) died (2644 while on the waiting list and 3025 after being delisted). Estimated 5-year survival was 77% (interquartile range [IQR], 74% to 80%) among transplant recipients and 33% (IQR, 17% to 51%) among those who did not undergo heart transplant, which is a survival benefit of 44% (IQR, 27% to 59%). Survival benefit ranged from 30% to 55% across centers and 31 centers (27%) had significantly higher survival benefit than the mean and 30 centers (27%) had significantly lower survival benefit than the mean. Compared with low survival benefit centers, high survival benefit centers performed heart transplant for patients with lower estimated expected waiting list survival without transplant (29% at high survival benefit centers vs 39% at low survival benefit centers; survival difference, −10% [95% CI, −12% to −8.1%]), although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers (77.6% vs 77.1%, respectively; survival difference, 0.5% [95% CI, −1.3% to 2.3%]). Overall, for every 10% decrease in estimated transplant candidate waiting list survival at a given center, there was an increase of 6.2% (95% CI, 5.2% to 7.3%) in the 5-year survival benefit associated with heart transplant.

Conclusions and Relevance  In this registry-based study of US heart transplant candidates, transplant center was associated with the survival benefit of transplant. Although the adjusted 5-year survival after transplant was not significantly different between high and low survival benefit centers, compared with centers with survival benefit significantly below the mean, centers with survival benefit significantly above the mean performed heart transplant for recipients who had significantly lower estimated expected 5-year waiting list survival without transplant.

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Article Information

Corresponding Author: William F. Parker, MD, MS, Department of Medicine, University of Chicago, 5841 S Maryland Ave, MC 6076, Chicago, IL 60637 (william.parker@uchospitals.edu).

Accepted for Publication: September 9, 2019.

Author Contributions: Dr Parker had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Parker, Gibbons, Garrity, Churpek.

Acquisition, analysis, or interpretation of data: Parker, Anderson, Garrity, Ross, Huang, Churpek.

Drafting of the manuscript: Parker, Gibbons, Churpek.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Parker, Gibbons, Churpek.

Obtained funding: Parker.

Administrative, technical, or material support: Churpek.

Supervision: Anderson, Gibbons, Garrity, Huang.

Conflict of Interest Disclosures: Dr Gibbons reported serving as a consultant to Adaptive Testing Technologies, GlaxoSmithKline, and Pfizer. Dr Churpek reported receiving research support from EarlySense in Tel Aviv, Israel; and having a US patent pending for a risk stratification algorithm for hospitalized patients. No other disclosures were reported.

Funding/Support: This study was supported by grant T32 HL 007605-32 from the National Heart, Lung, and Blood Institute (awarded to Dr Parker); grants K24 DK105340 and P30 DK092949 from the National Institutes of Health (awarded to Dr Huang); and by career development award K08 HL121080 from the National Heart, Lung, and Blood Institute and grant R01 GM123193 from the National Institute of General Medical Sciences (both awarded to Dr Churpek).

Role of the Funder/Sponsor: The funding sponsors had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or preparation of the manuscript and decision to submit for publication.

Disclaimer: The data reported herein were supplied by the Minneapolis Medical Research Foundation (as the contractor for the Scientific Registry of Transplant Recipients). The interpretation and reporting of these data are the responsibility of the authors and should not be seen as an official policy or interpretation by the Scientific Registry of Transplant Recipients or the US government.

Additional Contributions: We acknowledge Nikhil Narang, MD (University of Chicago), and Andrew Levy, MD (University of Colorado), for important clinical insights and J. C. Rojas, MD (University of Chicago), for assistance with study design and analysis. None received compensation for their role in the study.

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