Abstract 15991: Multiple Listing Increases Access to Heart, Lung, Liver, and Kidney Transplantation

Abstract

Introduction: United Network for Organ Sharing (UNOS) policy allows solid organ transplant candidates to be listed at multiple centers simultaneously. As not all candidates have the resources needed for multiple-listing, this policy may advantage wealthier patients. Methods: Among adult first-time, single-organ candidates in the UNOS database between January 1, 2000 and December 31, 2013 who had a recorded waitlist outcome, we identified 33,928 patients waiting for heart (HT), 24,633 for lung (LuT), 103,332 for liver (LiT) and 223,644 for kidney transplantation (KT). We used propensity score matching to address imbalances among baseline covariates and conducted competing risk analyses of waitlist outcomes. Results: The proportion of multiple-listed patients (ML) was 2.0%, 3.4%, 6.0% and 12.0% among HT, LuT, LiT and KT candidates, respectively. Regardless of organ type, ML candidates were younger than single-listed (SL) patients (mean age 52 ± 1 vs. 54 ± 1), more likely to be insured privately (58.9% vs 51.1%) and less likely by Medicaid (5.8% vs 10.3%), and lived in ZIP codes with higher median incomes ($93,081 ± $12,772 vs $67,690 ± $9,205); all p-values <0.0001. ML patients had proportionally higher functional status in addition to organ-specific indicators of lower acuity at initial listing. Across all organs, ML patients had longer waiting times at their initial listing centers but higher eventual transplant rates (OR [95% CI] = 1.23 [1.03-1.47], 1.56 [1.31-1.86], 1.57 [1.49-1.66] and 2.01 [1.95-2.07] for HT, LuT, LiT and KT, respectively) and lower rates of death while waiting (0.66 [0.50-0.87], 0.83 [0.67-1.03], 0.63 [0.58-0.68] and 0.53 [0.51-0.55]). Differences in waitlist outcomes between ML and SL patients were maintained after propensity score matching across all organs and in some cases were greatly accentuated. There were no consistent differences in post-transplant outcomes. Conclusions: Multiple listing is a rational response to organ shortage and long waiting times but appears to advantage patients with means to utilize it rather than the most medically needy. The UNOS multiple listing allowance should be reconsidered.