Same Game New Rules: What is the Impact of the 2018 UNOS Heart Allocation Change?

Abstract

The 2018 UNOS heart allocation policy shifted priority from patients supported with durable devices to those with temporary mechanical support. We sought to quantify the implications of this change including impact on wait times, hospital bed utilization and use of mechanical circulatory support devices. This study was a retrospective review of 32 consecutive patients who underwent heart transplantation at a single center between October 2017 and May 2019. Patient charts were reviewed for information regarding preoperative characteristics, operative data, and perioperative characteristics. Univariate analysis compared demographics and outcomes before and after the October 2018 policy change. There were 16 patients each in the pre and post policy-change groups. Patients did not differ significantly in their demographic profiles. Significant differences were noted, however, in the time on transplant list with median days of 166 before vs. 18.5 after policy change (p= .017), and in the presence of preoperative temporary support (12.5% vs. 68.75%, p= .011). Prior to the allocation change most heart transplant patients were admitted from home on the day of transplant (9/16 vs. 6/16), while afterwards the average preoperative length of stay was 14.7 days with the majority of these days as ICU status (11.06). Operative times were shorter (593 vs. 685 median minute, p= .0026) in the post allocation change group. There was no difference in operating room blood transfusions, postoperative outcomes, or postoperative length of stay between the groups. This study suggests that following the 2018 policy change, patients who received heart transplants experienced shorter waitlist times, longer preoperative hospital stays, and had an increased use of temporary mechanical assist devices. This shift to a resource intensive inpatient management strategy has implications that will require further evaluation.