Disparities in Listing With a Durable Left Ventricular Assist Device After 2018 Heart Allocation Policy Change.

BACKGROUND

Following the 2018 U.S. heart allocation policy change, transplant centers became less likely to use a bridge-to-transplant (BTT) durable left ventricular assist device (LVAD) strategy. Previous work has shown that patients with BTT LVADs are less likely to be transplanted under this current allocation policy. Candidates from vulnerable communities also have lower transplant rates after listing.

OBJECTIVES

The authors sought to determine if listing with BTT-LVADs disproportionately changed in vulnerable communities after the 2018 policy change.

METHODS

This study used data from the SRTR (Scientific Registry of Transplant Recipients). The study cohort included adult heart transplant candidates initially listed between 2014 and 2024, divided into prepolicy and postpolicy cohorts (before or after October 18, 2018). The primary exposure was neighborhood deprivation, measured by the national ADI (Area Deprivation Index) of the candidate's place of residence. The association of the interaction of ADI and policy period and the odds of a candidate being listed with a BTT-LVAD were estimated using a mixed-effects logistic regression model with a random intercept based on the listing center, adjusted for center characteristics and candidate characteristics.

RESULTS

The final study cohort included 43,342 candidates (17,655 prepolicy candidates and 25,687 postpolicy candidates). During the prepolicy period, 4,440 (25%) candidates were listed with a BTT-LVAD, compared to 4,658 (18%) under the current policy (P < 0.001). In our fully adjusted model, the impact of the candidate ADI on the likelihood of a candidate being listed with a BTT-LVAD differed significantly between policy periods (P < 0.001). In the prepolicy period, the ADI was not associated with odds of listing with a BTT-LVAD (prepolicy OR: 1.00 [95% CI: 0.98-1.02]; P > 0.9). In the postpolicy period, candidates in the 10th ADI decile (most disadvantage) had 59% higher odds of listing with a BTT-LVAD than first-decile candidates (postpolicy OR: 1.05 [95% CI: 1.03-1.08]; P < 0.001).

CONCLUSIONS

After the 2018 heart allocation policy change, candidates from more vulnerable communities became more likely to be listed with a BTT-LVAD. This change in practice may exacerbate place-based disparities in heart transplant access. Policy changes are needed to ensure greater equity among candidates being listed with a BTT-LVAD and heart allocation.