Background
Social factors like race and insurance affect transplant outcomes. However, little
is known in pediatric heart transplantation. We hypothesized that race and insurance
coverage impact listing and waitlist outcomes across eras.
Methods
Data from the Pediatric Heart Transplant Society multi-center registry prospectively
collected between January 1, 2000-December 31, 2019 were analyzed. Patients were divided
by race as Black, White and other and by insurance coverage at listing (US governmental,
US private and non-US single payer systems (UK, Canada). Clinical condition at listing
and waitlist outcomes were compared across races and insurance coverages. Categorical
variables were compared using a chi-square test and continuous variables using the
Wilcoxon rank sum test. Risk factors for waitlist mortality were examined using multiphase
parametric hazard modeling. A sensitivity analysis using parametric hazard explored
the interaction between race and insurance.
Results
At listing, compared to Whites (n = 5391) and others (n = 1167), Black patients (n = 1428) were older, more likely on US governmental insurance and had cardiomyopathy
as the predominant diagnosis (p < 0.0001). Black patients were more likely to be higher status at listing, in hospital,
on inotropes or a ventricular assist device (p < 0.0001). Black patients had significantly shorter time on the waitlist compared
to other races (p < 0.0001) but had higher waitlist mortality (p = 0.0091), driven by the earlier era (2000-2009) (p = 0.0005), most prominently within the US private insurance cohort (p = 0.015). Outcomes were not different in other insurance cohorts or in the recent
era (2010-2019).
Conclusion
Black children are older and sicker at the time of listing, deteriorate more often
and face a higher wait list mortality, despite a shorter waitlist period and favorable
clinical factors, with improvement in the recent era associated with the recent US
healthcare reforms. The social construct of race appears to disadvantage Black children
by limiting referral, consideration or access to pediatric cardiac transplantation.
KEYWORDS
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Article info
Publication history
Published online: December 07, 2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 International Society for Heart and Lung Transplantation. All rights reserved.