Heart Transplant Disparities Tied to Center-Level Decisions

Key Takeaways

• Breathett and colleagues associated lower first donor-heart offer acceptance with transplant centers caring for higher proportions of Black candidates and lower proportions of white candidates.
• Black patients were less likely than white patients to have a first donor-heart offer accepted in the initial adjusted analysis, but that difference no longer appeared after adjustment for center variability.
• Geography and transplant-center volume did not explain the observed pattern in first donor-heart offer acceptance.

Breathett and colleagues in Circulation: Heart Failure associated lower first donor-heart offer acceptance with transplant centers caring for higher proportions of Black candidates and lower proportions of white candidates. Black patients were less likely than white patients to have a first donor-heart offer accepted in the initial adjusted analysis, but that difference was no longer evident after accounting for variability across transplant centers; the authors further reported that lower first-offer acceptance across centers, in aggregate, contributes to racial differences in access to donor hearts in the United States.

The investigators focused on the first donor-heart offer because early acceptance behavior appeared to shape whether later offers would be accepted. Included centers had accepted at least 5 women, 5 men, 5 Black patients, and 5 white patients, and the analysis adjusted for donor-, patient-, and center-related factors that the investigators described as relevant to real-world acceptance decisions. Within that framework, geography and transplant-center volume were examined and did not account for the observed disparity.

For context, the earlier JAMA analysis of heart-offer acceptance sequence found that, among hearts ultimately accepted, acceptance occurred earliest for white women and latest for Black men. Breathett linked that pattern to wait-list experience as well, describing shorter wait-list time for women and longer wait-list time for Black men, and sex differences persisted after adjustment for center variability, with offers accepted first more often for women than for men.

Breathett also noted that UNOS implemented a donor-acceptance data-collection change in 2024 and that low overall acceptance rates could be subject to public reporting and penalties. She raised center dynamics, expertise, urgency, and overnight decision structure as possible explanations for between-center differences while stating that those ideas were not drawn from data in the current analysis. The reasons some centers differ in first-offer acceptance remain unclear and require further study.

Clinician Questions

How did first donor-heart offer acceptance differ at transplant centers serving higher proportions of Black candidates?

Breathett and colleagues reported lower first donor-heart offer acceptance rates at centers with higher proportions of Black patients and lower proportions of white patients than at centers with the opposite racial patient mix, and geography and transplant-center volume did not explain that pattern.

Did adjustment for transplant-center variability change the Black-white gap in first donor-heart offer acceptance?

Black patients were initially less likely than white patients to have a first donor-heart offer accepted, but that difference disappeared after adjustment for transplant-center variability, which the authors interpreted as pointing to center-level practices as a contributor to the disparity.

What did the earlier 2024 JAMA heart-transplant analysis report about white women and Black men?

Among hearts ultimately accepted, the earlier 2024 JAMA analysis described acceptance as earliest for white women and latest for Black men, and Breathett linked that pattern to shorter wait-list time for women and longer wait-list time for Black men.