Bias in the U.S. Heart Transplantation System

In the U.S., not enough hearts from donors are available to match the need for transplantation. Priority status for transplantation is based on the therapies that patients receive and not on objective indicators of heart failure. Some clinicians are concerned that less-ill patients (i.e., not in cardiogenic shock) are overtreated (e.g., with inotropes and intra-aortic balloon pumps) to increase their priority status to 1A, thus improving their chances of receiving a transplant. Studying the variation in treatment practices at heart transplantation centers might provide insight into their strategies for raising the priority status of their patients.

Investigators used a complete national registry to evaluate center-level variation in the treatment of heart transplantation candidates from 2010 through 2015. Of 12,726 candidates without cardiogenic shock at 108 centers, 12% were treated with high-dose inotropes or an intra-aortic balloon pump and listed as Status 1A (range in centers, 0%–68%). Centers in the highest quartile of potential overtreatment had a significantly higher rate than centers in the lowest quartile (28% vs. 2%). Higher rates occurred in more competitive environments, with the highest rates found in the three largest urban areas.