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

William F. Parker; Allen S. Anderson; Donald Hedeker; Elbert S. Huang; Edward R. Garrity; Mark Siegler; Matthew M. Churpek

doi:10.1016/j.jacc.2018.02.030

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

William F. Parker^*, Allen S. Anderson, Donald Hedeker, Elbert S. Huang, Edward R. Garrity, Mark Siegler, Matthew M. Churpek

^*Corresponding author for this work

Medicine, Cardiology Division

Research output: Contribution to journal › Article › peer-review

22 Scopus citations

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.

Original language	English (US)
Pages (from-to)	1715-1725
Number of pages	11
Journal	Journal of the American College of Cardiology
Volume	71
Issue number	16
DOIs	https://doi.org/10.1016/j.jacc.2018.02.030
State	Published - Apr 24 2018

Funding

Supported in part by institutional Clinical and Translational Science Award grant UL1 RR024999. Dr. Parker is supported by National Institutes of Health T32 Training grant 5T32HL007605-32. Dr. Anderson has received consulting fees from GE HealthCare; and has served on the speakers bureau for Novartis and Relypsa. Dr. Churpek is supported by National Institutes of Health grants K08 HL121080-03 and R01 GM 123193; and has a patent pending (ARCD.P053US.P2) for risk stratification algorithms. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Keywords

ethics
heart transplantation
organ allocation

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

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10.1016/j.jacc.2018.02.030

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@article{8a591cd7b4464ece97196cdb2e79ddde,

title = "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.",

keywords = "ethics, heart transplantation, organ allocation",

author = "Parker, {William F.} and Anderson, {Allen S.} and Donald Hedeker and Huang, {Elbert S.} and Garrity, {Edward R.} and Mark Siegler and Churpek, {Matthew M.}",

note = "Funding Information: Supported in part by institutional Clinical and Translational Science Award grant UL1 RR024999. Dr. Parker is supported by National Institutes of Health T32 Training grant 5T32HL007605-32. Dr. Anderson has received consulting fees from GE HealthCare; and has served on the speakers bureau for Novartis and Relypsa. Dr. Churpek is supported by National Institutes of Health grants K08 HL121080-03 and R01 GM 123193; and has a patent pending (ARCD.P053US.P2) for risk stratification algorithms. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: {\textcopyright} 2018 American College of Cardiology Foundation",

year = "2018",

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doi = "10.1016/j.jacc.2018.02.030",

language = "English (US)",

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pages = "1715--1725",

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T1 - Geographic Variation in the Treatment of U.S. Adult Heart Transplant Candidates

AU - Parker, William F.

AU - Anderson, Allen S.

AU - Hedeker, Donald

AU - Huang, Elbert S.

AU - Garrity, Edward R.

AU - Siegler, Mark

AU - Churpek, Matthew M.

N1 - Funding Information: Supported in part by institutional Clinical and Translational Science Award grant UL1 RR024999. Dr. Parker is supported by National Institutes of Health T32 Training grant 5T32HL007605-32. Dr. Anderson has received consulting fees from GE HealthCare; and has served on the speakers bureau for Novartis and Relypsa. Dr. Churpek is supported by National Institutes of Health grants K08 HL121080-03 and R01 GM 123193; and has a patent pending (ARCD.P053US.P2) for risk stratification algorithms. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Publisher Copyright: © 2018 American College of Cardiology Foundation

PY - 2018/4/24

Y1 - 2018/4/24

N2 - 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.

AB - 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.

KW - ethics

KW - heart transplantation

KW - organ allocation

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

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