Geographic Variation in Treatment of Heart Transplant Candidates

Study Questions:

What is the national variation in the intensity of treatment of adult heart transplantation candidates, and what are center-level predictors of potential overtreatment?

Methods:

The study cohort was comprised of US adult heart transplant candidates from the Scientific Registry of Transplant Recipients. The authors defined “potential overtreatment” as treatment of a candidate who did not meet American Heart Association cardiogenic shock criteria with either high-dose inotropes or an intra-aortic balloon pump. There are legitimate nonhemodynamic reasons, such as very poor functional status, end-organ jeopardy, or the inability to use durable mechanical circulatory support, to treat a candidate with intensive therapies not strictly indicated by hemodynamic measurements. Therefore, they accounted for differences in nonhemodynamic candidate characteristics using two different methods—multilevel logistic regression and propensity score models to adjust for candidate variability at each center. Center-level variables associated with potential overtreatment were identified.

Results:

From 2010 to 2015, there were 19,919 adult heart-only candidate listings with 12,726 noncardiogenic shock candidates at risk for potential overtreatment listed at 108 centers within 51 organ procurement organizations (OPOs). The investigators found that 11.6% (n = 1,471) were potentially treated with high-dose inotropes or intra-aortic balloon pumps and listed as Status 1A, 5,369 (42.1%) were listed as Status 1B, and 5,922 (46.4%) were listed as Status 2. In the bottom quartile of centers, only 2.1% of candidates were potentially overtreated compared with 27.6% at top quartile centers, an interquartile difference of 25.5% (95% confidence interval, 21-30%). Adjusting for candidate differences did not significantly alter the interquartile difference. Local competition with ≥2 centers increased the odds of potential overtreatment by 50% (adjusted odds ratio, 1.50; 95% confidence interval, 1.07-2.11). There is substantial intraregional variation, with neighboring OPO often having dramatically different potential overtreatment rates. Of note, the three largest urban areas in the United States (New York, Chicago, and Los Angles) have high rates of potential overtreatment.

Conclusions:

The authors concluded that there is wide variation in the treatment practices of adult heart transplantation centers, and that competition for transplantable donor hearts is associated with the potential overtreatment of hemodynamically stable candidates.

Perspective:

This is an important study because it ‘suggests’ that centers may be winging the system to get ahead of the queue. However, as the authors point out, hemodynamic criteria do not completely capture the severity of the patient’s illness. This paper should stimulate development of an objective scoring system for allocation of hearts to allow fair apportionment of this scarce resource.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Cardiac Surgical Procedures, Heart Failure, Heart Transplantation, Hemodynamics, Intra-Aortic Balloon Pumping, Shock, Cardiogenic, Tissue and Organ Procurement, Tissue Donors, Transplantation, Treatment Outcome


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