Abstract 10540: Worsening Racial Disparity in Waitlist Mortality for Pediatric Heart Transplant Candidates Since the 2016 Pediatric Heart Allocation Policy Revision

Abstract

Introduction: The US Pediatric Heart Allocation Policy was recently revised with the goal of lowering waitlist mortality. Effective March 2016, these rules significantly changed the requirements for priority status. We evaluated the hypothesis that this change, which has led to an increase in status exceptions, has worsened known racial disparities in waitlist outcomes. Methods: Children in the Pediatric Heart Transplant Study database listed at a US center from January 2012 - June 2020 were included and stratified by listing before (Era 1) or after (Era 2) allocation policy change on March 22, 2016. Competing risk survival analysis was performed to evaluate endpoint of death or deterioration on the waitlist with transplant treated as a competing risk. Results: Compared with white children (n=2,648), non-white children (n=1,441) were more likely to have an underlying diagnosis of cardiomyopathy (49% vs. 39%, p<0.001), be currently hospitalized (81% vs. 71%, p=0.007) and supported with a ventricular assist device (VAD) (12% vs 9%, p=0.005) at the time of listing. Waitlist mortality was similar in white and non-white children in Era 1, but worse for non-white children compared to white children in Era 2 (Figure). In multivariable analysis controlling for diagnosis, age and severity markers, non-white children had a significantly higher waitlist mortality only if listed after the policy change (Era 1: sHR 1.18 [95%CI 0.88 - 1.59] vs. Era 2: sHR 1.52 [95%CI 1.14 - 2.02]). Hispanic ethnicity was not associated with waitlist mortality in either period when controlling for other risk factors. Conclusions: Widening racial disparities in waitlist mortality may be an unintended consequence of the 2016 Pediatric Heart Allocation Policy revision. Additional analyses may help the transplant community understand the degree to which this policy (i.e. prioritized listing status and exceptions) vs. unrelated changes in care differentially contribute to these disparities.