Review Examines Outcomes of 2018 Changes to Donor-Heart Allocation in the United States
A new review article published by The Texas Heart Institute President and CEO Joseph G. Rogers, MD, and colleagues suggests that changes made in 2018 to the policies that guide the allocation of donor hearts to patients with severe heart failure have been beneficial to these patients.
The United Network for Organ Sharing (UNOS) is the arm of the U.S. Organ Procurement and Transplant Network that dictates organ transplant policy in the United States. For patients with heart failure severe enough to necessitate a heart transplant, one of the principal aims of UNOS’s policies is to maximize the number of these patients who receive a donor heart. Achieving this aim has grown more difficult over time: The number of U.S. patients in need of a heart transplant has doubled since 2006, while the number of available donor hearts has been largely unchanged.
In 2018, UNOS updated its heart allocation policy in an effort to close the gap between need and supply. Changes included making the criteria for stratifying patients by disease severity more objective and more detailed, and patients are now stratified into 6 tiers of priority for transplant instead of the previous 3 tiers.
In an article recently published in JACC: Heart Failure, Dr. Rogers and colleagues reviewed the literature regarding how these policy changes have affected patient outcomes in the years since their implementation.
“Probably the greatest benefit of the policy changes,” says Dr. Rogers, “is that because only the most severely ill patients are placed in the highest categories, these high-priority patients are spending much less time on the waitlist and receive their transplants much sooner. This is true for many of the lower-priority patients, too; as a result, overall waitlist time has decreased from 112 days to 39 days.”
The review found that waitlist mortality is similar or slightly lower with the new system. This result is meaningful given that the proportion of patients with the most severe heart disease has increased in recent years. The authors suggest that the more frequent use of mechanical circulatory support in patients awaiting transplant may help explain this benefit.
The policy changes are not without drawbacks. Transport costs for donor hearts have increased, as has the expense of hospitalizing patients for the transplant procedure. However, these increases may be offset by cost reductions associated with the shorter waitlist times and decreased long-term use of mechanical circulatory support.
“Overall, UNOS’s changes in the way donor hearts are allocated appear to have benefitted patients with heart failure,” Dr. Rogers concludes. “Nonetheless, there is room for refinements that would better account for the severity of patients’ illness in determining their priority for transplant, so the research must continue.”
Notably, the study’s first three authors are physicians in training. Neil S. Maitra, MD, and Samuel J. Dugger, MD, are third-year Internal Medicine residents at Baylor College of Medicine, and Isabel C. Balachandran, MD, is a third-year fellow in The Institute’s Cardiovascular Disease Fellowship at Baylor St. Luke’s Medical Center.
Maitra NS, Dugger SJ, Balachandran IC, Civitello AB, Khazanie P, Rogers JG. Impact of the 2018 UNOS Heart Transplant Policy Changes on Patient Outcomes. JACC Heart Fail. 2023 Feb 16;S2213-1779(23)00038-0. doi:10.1016/j.jchf.2023.01.009
News Story By Stephen N. Palmer, PhD, ELS