Impact of Race on Listing and Waitlist Mortality in Pediatric Cardiac Transplantation

Abstract

PurposeSocial factors like race and insurance affect transplant outcomes. However, there is paucity of data and reasons remain unclear. We hypothesized that social factors affect clinical condition at listing and waitlist outcomes.MethodsData from prospectively collected multi-center registry of the Pediatric Heart Transplant Society between January 1, 2000- December 31, 2019 were analyzed. Patients (pts) were divided by race as black, white, other (including those with multiple selections). Listing variables were analyzed using analysis of variance and chi-square test and waitlist outcomes by Kaplan Meier log rank test.ResultsOf 8284 pts listed for cardiac transplantation, 5565 were white, 1455 black and 1264 other. Compared to whites and others, black pts at listing were older (6.4yrs vs 5.6yrs vs 5.6yrs; p<0.001), more likely on US governmental insurance (69.8% vs 41.8% vs 50.2%; p<0.001) and had cardiomyopathy as the predominant diagnosis compared to congenital heart defect (CHD) (50.9% vs 44.3%). Black pts were more likely to be UNOS status 1A (73.7% vs 67.1% vs 64%), have higher priority status (82.7% vs 77.8% vs 75.2%), be in hospital (83% vs 75.2% vs 75.5%) and receive inotropes (66.3% vs 59% vs 58.3%) (p<0.001 for all factors). There were more ventricular assist devices in black pts compared to whites (8.6% vs 6.4%; p<0.001). Fewer black pts received a transplant for CHD (p=0.0005). Black pts had significantly higher waitlist mortality compared to whites and others (p=0.0038, figure), especially comparing US private health insurance (p=0.015), while outcomes were similar for US-governmental and single payer systems (UK, Canada).ConclusionBlack pts are sicker at listing and face higher waitlist mortality despite older age and a greater proportion of cardiomyopathy, typically associated with better outcomes. This suggests that the social construct of race negatively impacts consideration of, access or referral to pediatric cardiac transplantation, independent of access to private insurance coverage. Social factors like race and insurance affect transplant outcomes. However, there is paucity of data and reasons remain unclear. We hypothesized that social factors affect clinical condition at listing and waitlist outcomes. Data from prospectively collected multi-center registry of the Pediatric Heart Transplant Society between January 1, 2000- December 31, 2019 were analyzed. Patients (pts) were divided by race as black, white, other (including those with multiple selections). Listing variables were analyzed using analysis of variance and chi-square test and waitlist outcomes by Kaplan Meier log rank test. Of 8284 pts listed for cardiac transplantation, 5565 were white, 1455 black and 1264 other. Compared to whites and others, black pts at listing were older (6.4yrs vs 5.6yrs vs 5.6yrs; p<0.001), more likely on US governmental insurance (69.8% vs 41.8% vs 50.2%; p<0.001) and had cardiomyopathy as the predominant diagnosis compared to congenital heart defect (CHD) (50.9% vs 44.3%). Black pts were more likely to be UNOS status 1A (73.7% vs 67.1% vs 64%), have higher priority status (82.7% vs 77.8% vs 75.2%), be in hospital (83% vs 75.2% vs 75.5%) and receive inotropes (66.3% vs 59% vs 58.3%) (p<0.001 for all factors). There were more ventricular assist devices in black pts compared to whites (8.6% vs 6.4%; p<0.001). Fewer black pts received a transplant for CHD (p=0.0005). Black pts had significantly higher waitlist mortality compared to whites and others (p=0.0038, figure), especially comparing US private health insurance (p=0.015), while outcomes were similar for US-governmental and single payer systems (UK, Canada). Black pts are sicker at listing and face higher waitlist mortality despite older age and a greater proportion of cardiomyopathy, typically associated with better outcomes. This suggests that the social construct of race negatively impacts consideration of, access or referral to pediatric cardiac transplantation, independent of access to private insurance coverage.