The Effect of the New UNOS Heart Allocation on Donation Service Area and Heart Transplant Program Logistics: The Mid America Experience

Abstract

A revised U.S. heart allocation system (HAS) instituted 10/18/18 was designed to eliminate donation service area (DSA) boundaries/reduce geographic disparity. The new status 1-3 is equivalent to the old status 1A. The effect of HAS change on DSA and heart transplant program (HTP) logistics are unknown. We report our DSA and HTP experience 1 year later. Data from 2 groups of patients defined by date of transplant were analyzed: pre HAS change (PRE, 10/18/17-10/17/18) and post HAS change (POST, 10/18/18-9/30/19). The data from our local DSA and our HTP PRE and POST are reported separately. Our local DSA has 2 adult/1 pediatric HTPs. During the PRE, the DSA recovered 65 adult hearts (30 allocated to our HTP, 13 to 2nd adult HTP, 1 to pediatric HTP). 21 hearts were allocated outside of the DSA (32.3%). 40 hearts were allocated to status 1A (62%). During the POST, the DSA recovered 75 adult hearts (10 allocated to our HTP, 4 to 2nd adult HTP). 61 (81.3%) hearts were allocated outside the DSA. 84% were allocated to the old status 1A equivalent (new status 1-3). Table illustrates our HTP statistics PRE and POST. 38 transplants were performed PRE, and 40 performed POST. Cold ischemic time increased 21% from 161 to 195 minutes. Flights were required in 15 PRE and 34 POST cases. While the miles per flight were similar PRE and POST (331 vs 354 nautical miles [nm]), the total nm increased 2.4 fold from 4969 to 12032. Travel time increased 25% from 251 to 315 minutes. Total organ acquisition cost increased 36% per transplant POST vs PRE. After HAS change, 81% (vs 32%) of hearts were allocated outside the DSA and to the most urgent statuses (84 vs 62%). HAS change led to significant increase in cold ischemic time (21%), travel time (25%)/distance (242%), need for procurement team flyout (34 vs 15) and per transplant organ acquisition cost (36%). Further analysis are needed to examine the impact of HAS on procurement logistics, HTP cost, surgeon travel safety and post transplant survival.