Racial Disparities in Outcomes of Adult Heart Transplantation
Background—This study evaluated whether minority orthotopic heart transplant (OHT) recipients tend to be transplanted at worse performing centers.
Methods and Results—OHT recipients between 2000-2010 were identified in the United Network for Organ Sharing database and stratified by race. Center performance was evaluated using observed-to-expected mortality ratios (OEs) that were calculated using validated indices for recipient and donor risk in OHT. The primary outcome was 1-year post-OHT mortality. 102 centers performed OHT in 18,085 patients. Blacks had higher unadjusted 1-year mortality, which was confirmed after risk adjustment. Blacks had increased risk-adjusted mortality at poor performing centers (OE>1.2; OR 1.37, 95% CI 1.12-1.69; p=0.002) and a strong trend towards increased mortality at excellent performing centers (OE<0.8; OR 1.42, 95% CI 0.99-2.02; p=0.06). A higher proportion of blacks were treated at centers with higher than expected mortality (56.4% versus 47.1% whites versus 48.1% Hispanics; p<0.001), a finding that persisted after adjusting for insurance type and highest education level. In addition, there was a positive correlation between percentage of blacks and OEs at the center level (r=0.32; p=0.001). In multivariable analysis incorporating immunologic and socioeconomic variables, there was no clear dominant source for the disparities in outcomes of OHT between races.
Conclusions—Blacks have a propensity to be transplanted at worse performing centers, however, center effect alone does not explain the mortality difference between ethnicities. Although referral of minorities to better performing centers would improve absolute survival, it would not likely eliminate the racial disparities that exist in OHT outcomes.
- Received June 11, 2014.
- Revision received January 2, 2015.
- Accepted January 5, 2015.