Wpatient If you have end-stage heart failure, the best treatment is to undergo a heart transplant. The basic steps are well known. First, patients are placed on a waiting list and then they start waiting for an offer. Although access to donor hearts has increased in recent years thanks to changes in heart allocation policies, disparities based on gender and race still exist in the acceptance rate of donor heart offers by transplant teams, the report said. states. New research published on Monday Published in the Journal of the American Medical Association.meanwhile Both white and black women were more likely to have their donated hearts accepted by the transplant team, but black men waited the longest for a transplant because their hearts were repeatedly rejected by transplant centers. Some transplant experts say high rejection rates could lead to longer wait times and higher death rates for black men while waiting.
Lead author Khadijah Brissett said the discovery was “really strange.” Black men had the highest number of matched offers before they were accepted, compared to far fewer women, especially white women. Blacks were significantly less likely than whites to have any offer accepted. The median number of offers was 11 for black men, 7 for black women, 9 for white men, and 5 for white women, researchers said.
The high acceptance rate among women initially surprised Brissett, but Because there’s no reason why men have to wait longer.
“Personally, I think this is probably related to stigma,” said Brisette, an advanced heart failure transplant cardiologist at Indiana University Health. She told STAT that doctors are probably thinking: Whereas you think, “Oh, this woman can’t wait, we can’t wait. This works. Take it. Let’s take it and go with it.” But men think they’re more solid. Prejudice and systemic racism may be unintentional, but the power of stereotypes in society and how they often influence decision-making is important. It shows how it affects you.
Once a patient is a candidate for a heart transplant, matching occurs through a standardized process. Computer algorithms rank and match candidates and donors based on a variety of characteristics, including urgency, transplant center location, blood type, and donor hospital location. Then, once the transplant center receives an offer, the donor is matched with the next candidate. The transplant team reviews the donor’s data and decides whether to accept or reject the organ. However, while the matching process is done according to an algorithm, the decision to accept a transplant team’s offer takes into account special factors that doctors consider when determining whether a donor heart is a match for a patient. It gets a little more subjective.
“For anyone who cares for patients with advanced heart failure, this study should make us pause and take a moment to not only introspect, but also reflect on how the program is being run in particular, and the process as a whole in general. “It will give us the best possible results,” said senior physician Michelle Kittleson. He is a heart failure transplant cardiologist and director of heart failure research at the Smit Heart Institute at Cedars-Sinai. Although she was not involved in the study, she commented that her study was “beautiful” and well-done.of Unified network for organ sharing Kittleson said these data can provide important signals and trends and highlight unmet needs in patients with advanced heart failure.
In 2018, heart transplant allocation policies changed to prioritize the sickest patients. As a result, the number of hearts transplanted in all groups increased significantly. Additionally, waiting times have been reduced from several months to up to one month. This includes black patients who were least likely to receive a transplant but did not receive one. 26% of all transplants However, disparities remain prevalent, with black patients and women less likely to receive heart transplants than white patients and men. For black people too, 50% more likely They are more likely to develop heart failure than whites.
Breathett and colleagues reviewed the UNOS dataset from 2018 to 2023 to reflect changes to the new allocation policy. They compared non-Hispanic black and white patients in the United States.
During that period, 159,177 heart offers resulted in 13,760 donor hearts available. There were 14,890 heart transplant candidates, of whom 30.9% were black, 69.1% were white, 73.6% were male, and 26.4% were female.
After adjusting for various variables such as patient, donor, and offer considerations, black candidates were 24% less likely to have their first offered heart accepted compared to white candidates. Black candidates remained less likely than white candidates to have their offers accepted by the 16th offer. Additionally, when gender was taken into account, female candidates were 53% more likely to accept a job offer. Additionally, women were more likely than men to have their offers accepted by the sixth person.
Jamin Trivedi, an associate professor of cardiovascular and thoracic surgery at the University of Louisville, who was also not involved in the study, said that when patients receive implantable medical devices, such as left ventricular assist devices (LVADs), they are given lower priority. It pointed out. For that patient, that could mean a difference in offer. In this study, 32% of black men had their LVAD compared to 26% of white men. And that rate was lower among black women (25%) and white women (17%).
Researchers who spoke to STAT generally believe it is prudent to focus on data after the introduction of a new allocation system, so mechanical assist devices such as ECMO (extracorporeal membrane oxygenation) The impact of a new system to prioritize critically ill patients in need was evaluated. “Unfortunately, what that means is that it is in high-income areas that can provide devices like ECMO to patients.it looks like we can get more hearts,” said Ashishana Osho, an advanced transplant cardiologist at Massachusetts General Hospital.
The study authors say further research is needed to change the decision-making that may be contributing to these disparities.
“I don’t think we’ve proven that African Americans receive worse care than other people, or that men receive worse care than women. I don’t think we can conclude that. “But we see worrying disparities with no clear explanation,” said Paul Heiden, a noninvasive cardiologist, professor, and vice chair for quality at Stanford University and co-author of the JAMA editorial. Reich said. study.
Regarding limitations, researchers say no adjustments were made for donor data such as heart quality or presence of coronary artery disease. Both Trivedi and Heidenreich believe that including information about BMI and blood type would have been additional information that would have helped them analyze cardiac offer acceptance rates.
Moving forward, Brisette said transplant centers will need to obtain more data and look for patterns in how they are accepting or not accepting donors based on race, ethnicity and gender. It is possible that some centers consider their own statistics and decline the offer. “This means that some people of color may choose not to undergo a transplant in order to reduce negative outcomes and avoid being penalized,” Brissett said. Kittleson said it’s important for the center to “think more deeply, with an open mind to the biology and all the potential causes of disparities, and enact changes that bring more equity in the process.” He said that.
