Regional Variation in Survival Before and After Pediatric Heart Transplantation—An Analysis of The UNOS Database

Abstract

Geographic variation occurs in a variety of health outcomes. Regional influences on outcomes before and after listing for pediatric heart transplantation have not been assessed. Review of the UNOS dataset identified 5398 pediatric ( 18 years) patients listed for heart transplantation 2000-2011. Patients were stratified based on the region of listing. Regionallevel variables were correlated with individual riskadjusted outcomes. Mean time spent on the waitlist varied from 91.0 AE 163 days (Region 6 [R6]) to 248.1 AE 493 days (R4, p < 0.0001). Regions with more transplant centers (p < 0.0001) and fewer transplants (p ¼ 0.0015) had higher waitlist mortality. Risk-adjusted individual waitlist mortality varied from 6.9% (R1, CI 6.2-7.8) to 19.2% (R5, CI 18.0-20.6). Waitlist mortality was higher for individuals awaiting transplant in regions with more listings per center (OR 1.04, CI 1.01-1.08) and lower in regions with more donors per center (OR 0.95, CI 0.90-0.99 per donor). Posttransplant risk-adjusted survival varied across regions (R4: 5.4%, CI 4.2-7.4; R7: 18.0%, CI 12.4-32.5), but regional variables were not correlated with outcomes. Outcomes among children undergoing heart transplantation vary by region. Factors leading to increased competition for donor allografts are associated with poorer waitlist survival. Equitable allocation of cardiac allografts requires further investigation of these findings.

ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation

“…Geography likely plays a significant role in donor acceptance. Geographic location impacts waitlist time, 133,134 competition from other centers, 135 and donor availability 136,137 and may impact IT.…”

A comprehensive strategy in donor acceptance: Impact on pediatric waitlist and heart transplant outcomes

“…Death on the waitlist in the USA is variable (5%‐30%) depending on center volume and center location 26,27 . Our overall waitlist mortality was 14.3%.…”

Regional variation in the use of 1A status exceptions for pediatric heart transplant candidates: is this equitable?

“…There is significant geographic variability in waitlist times and access to transplantation . For this reason, listing strategies may need to differ based on location.…”

“…For this reason, listing strategies may need to differ based on location. Each HTx center has a different patient population, donor pool, and varying levels of competition from other HTx centers, and these regional differences have been shown to impact waitlist outcomes . These differences may also explain why UNOS region 6 appears as an outlier in our analysis, as this region contains only one pediatric HTx program.…”