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Geographic Variation in the Treatment of U.S. Adult Heart Transplant Candidates.

Abstract：

BACKGROUND:The current U.S. priority ranking for heart candidates is based on treatment intensity, not objective markers of severity of illness. This system may encourage centers to overtreat candidates. OBJECTIVES:This study sought to describe national variation in the intensity of treatment of adult heart transplantation candidates and identify center-level predictors of potential overtreatment. METHODS:The registrations of all U.S. adult heart transplantation candidates from 2010 to 2015 were collected from the SRTR (Scientific Registry of Transplant Recipients). "Potential overtreatment" was defined 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. Multilevel logistic regression and propensity score models were used to adjust for candidate variability at each center. Center-level variables associated with potential overtreatment were identified. RESULTS:From 2010 to 2015, 108 centers listed 12,762 adult candidates who were not in cardiogenic shock for heart transplantation. Of these, 1,471 (11.6%) were potentially overtreated with high-dose inotropes or intra-aortic balloon pumps. 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% to 30%). Adjusting for candidate differences did not significantly alter the interquartile difference. Local competition with 2 or more centers increased the odds of potential overtreatment by 50% (adjusted odds ratio: 1.50; 95% confidence interval: 1.07 to 2.11). CONCLUSIONS:There is wide variation in the treatment practices of adult heart transplantation centers. Competition for transplantable donor hearts is associated with the potential overtreatment of hemodynamically stable candidates. Overtreatment may compromise the fair and efficient allocation of scarce deceased donor hearts.

journal_name

J Am Coll Cardiol

journal_title

Journal of the American College of Cardiology

authors

Parker WF,Anderson AS,Hedeker D,Huang ES,Garrity ER Jr,Siegler M,Churpek MM

doi

10.1016/j.jacc.2018.02.030

subject

Has Abstract

pub_date

2018-04-24 00:00:00

pages

1715-1725

issue

eissn

0735-1097

issn

1558-3597

pii

S0735-1097(18)33308-4

journal_volume

pub_type

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Geographic Variation in the Treatment of U.S. Adult Heart Transplant Candidates.