Association of Race/Ethnicity, Inactivation on Waitlist for Socioeconomic Reasons, and Outcomes in Heart-Transplantation (HT)

Abstract

<h3>Purpose</h3> Transient waitlist inactivation (WI) can be due to medical, logistical (program or patient related), or for socioeconomic reasons (SER) like medical non-compliance, inappropriate substance use or insurance issues. We evaluated the association of race/ethnicity with WI for SER, subsequent reactivation and outcomes after HT. <h3>Methods</h3> Of 48,213 adult candidates for single organ HT meeting study criteria in UNOS, between June 2006 and February 2021, we identified n=2,812 HT candidates who had WI at least once for SERs (SER WI cohort), n=16,411 with WI for non-SERs and n=28,990 with no WI. The cohorts were compared for race/ethnicity, WI, and post-HT outcomes. We also evaluated this relationship across UNOS regions. Race/ethnicity was categorized as non Hispanic White (nH-W), non Hispanic Black (nH-B), Hispanic (H) and Asian/others. <h3>Results</h3> Compared to others, rate of HT was lower in SER-WI cohort (40.7% SER-WI, 46.1% non-SER WI and 83.3% no-WI, p<0.01). While nH-B constituted similar proportion in overall and non-SER WI cohorts (∼23%), they constituted disproportionately higher proportion of SER-WI cohort (33.3%). Overall, nH-B were more likely to be inactivated than nH-W for SERs, OR=1.70(1.55-1.86), p<0.01 using logistic regression, adjusted for candidate age, gender, height, BMI, ischemic etiology, blood group, LVAD, inotropes, education, projected insurance and listing status (Fig1A). Further, once inactivated for SERs, compared to nH-W, nH-B were less likely to be re-activated on the waitlist and receive HT or improve clinically to not needing HT; OR=0.56(0.45-0.71), p<0.01 adjusted for baseline differences (Fig1B). This pattern was consistent across UNOS regions. Finally, nH-B candidates in the SER-WI cohort who received HT, had a trend towards worse post-HT survival. <h3>Conclusion</h3> These results raise concerns for possible provider and HT center bias in evaluating socioeconomic risks (considered to be relative contraindications to HT) in nH-B candidates.