Heart transplantation centers that “potentially overtreat” candidates may compromise the fair and efficient allocation of scarce donor hearts, according to a study presented April 14 at the International Society for Heart and Lung Transplantation's Annual Meeting and Scientific Sessions in Nice, France, and simultaneously published in the Journal of the American College of Cardiology.

Using data from the Scientific Registry of Transplant Recipients, William F. Parker, MD, et al., examined the registrations of all U.S. adult heart transplantation candidates from 2010 – 2015 based on national variation in treatment intensity. “Potential overtreatment” was defined as treatment of a candidate who did not meet cardiogenic shock criteria with either high-dose inotropes or an intra-aortic balloon pump. A total of 12,762 adult candidates were listed as not in cardiogenic shock for heart transplantation.

Results showed that of these candidates, 1,471 (11.6 percent) were potentially overtreated with high-dose inotropes or intra-aortic balloon pumps. In the bottom quartile of transplantation centers, only 2.1 percent of candidates were potentially overtreated compared with 27.6 percent at top quartile centers, an interquartile difference of 25.5 percent (95 percent confidence interval [CI]: 21 percent to 30 percent). Adjusting for candidate differences did not significantly alter the interquartile difference.

Furthermore, local competition with two or more centers increased the odds of potential overtreatment by 50 percent (adjusted odds ratio: 1.50; 95 percent CI: 1.07 to 2.11). The author’s note that this competition for transplantable hearts may be the reason for overtreatment of hemodynamically stable heart transplant candidates.

The authors explain that widespread overtreatment can cause excess cost and unnecessary risk of therapy-related complications, as well as unfairly elevate the status of less urgent candidates. They conclude that therapy-based allocation systems will always be susceptible to manipulation and recommend developing an objective scoring system for heart allocation.

In an accompanying editorial comment, Larry A. Allen, MD, MHS, FACC, and Prateeti Khazanie, MD, MPH, note that while new allocation plans have the best intentions of solving disparities, fair play is not always natural. “Clinicians making heart transplant allocation decisions are rarely consciously and flagrantly overtreating patients to outwit, outplay and outlast one another,” they write. “We must continue to strive for an explicit and transparent system that ensures optimal fairness, within which clinicians can advocate for individual patients.”

Keywords: Odds Ratio, Shock, Cardiogenic, Transplantation, Confidence Intervals, Ambroxol, Heart Transplantation, Heart-Assist Devices, Tissue Donors, Registries, Lung Transplantation

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