Author + information
- Received December 1, 2017
- Revision received February 7, 2018
- Accepted February 7, 2018
- Published online April 16, 2018.
- William F. Parker, MDa,b,∗ (, )
- Allen S. Anderson, MDc,
- Donald Hedeker, PhDd,
- Elbert S. Huang, MDa,b,
- Edward R. Garrity Jr., MDa,b,
- Mark Siegler, MDa,b and
- Matthew M. Churpek, MD, PhDa
- aDepartment of Medicine, University of Chicago, Chicago, Illinois
- bMacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
- cCenter for Heart Failure, Blum Cardiovascular Institute, Northwestern Medicine, Chicago, Illinois
- dDepartment of Public Health Sciences, University of Chicago, Chicago, Illinois
- ↵∗Address for correspondence:
Dr. William F. Parker, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 6076, Chicago, Illinois 60637.
Background The current U.S. priority ranking for heart candidates is based on treatment intensity, not objective markers of severity of illness. This system may encourage centers to overtreat candidates.
Objectives This study sought to describe national variation in the intensity of treatment of adult heart transplantation candidates and identify center-level predictors of potential overtreatment.
Methods The registrations of all U.S. adult heart transplantation candidates from 2010 to 2015 were collected from the SRTR (Scientific Registry of Transplant Recipients). “Potential overtreatment” was defined as treatment of a candidate who did not meet American Heart Association cardiogenic shock criteria with either high-dose inotropes or an intra-aortic balloon pump. Multilevel logistic regression and propensity score models were used to adjust for candidate variability at each center. Center-level variables associated with potential overtreatment were identified.
Results From 2010 to 2015, 108 centers listed 12,762 adult candidates who were not in cardiogenic shock for heart transplantation. Of these, 1,471 (11.6%) were potentially overtreated with high-dose inotropes or intra-aortic balloon pumps. In the bottom quartile of centers, only 2.1% of candidates were potentially overtreated compared with 27.6% at top quartile centers, an interquartile difference of 25.5% (95% confidence interval: 21% to 30%). Adjusting for candidate differences did not significantly alter the interquartile difference. Local competition with 2 or more centers increased the odds of potential overtreatment by 50% (adjusted odds ratio: 1.50; 95% confidence interval: 1.07 to 2.11).
Conclusions There is wide variation in the treatment practices of adult heart transplantation centers. Competition for transplantable donor hearts is associated with the potential overtreatment of hemodynamically stable candidates. Overtreatment may compromise the fair and efficient allocation of scarce deceased donor hearts.
Supported in part by institutional Clinical and Translational Science Award grant UL1 RR024999. Dr. Parker is supported by National Institutes of Health T32 Training grant 5T32HL007605-32. Dr. Anderson has received consulting fees from GE HealthCare; and has served on the speakers bureau for Novartis and Relypsa. Dr. Churpek is supported by National Institutes of Health grants K08 HL121080-03 and R01 GM 123193; and has a patent pending (ARCD.P053US.P2) for risk stratification algorithms. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The data reported here have been supplied by the Minneapolis Medical Research Foundation as the contractor for the SRTR (Scientific Registry of Transplant Recipients). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the SRTR or the U.S. government.
- Received December 1, 2017.
- Revision received February 7, 2018.
- Accepted February 7, 2018.
- 2018 American College of Cardiology Foundation