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- Title
Comparison of Evaluations for Heart Transplant Before Durable Left Ventricular Assist Device and Subsequent Receipt of Transplant at Transplant vs Nontransplant Centers.
- Authors
Cascino, Thomas M.; McCullough, Jeffrey S.; Wu, Xiaoting; Pienta, Michael J.; Stewart II, James W.; Hawkins, Robert B.; Brescia, Alexander A.; Abou el ala, Ashraf; Zhang, Min; Noly, Pierre-Emmanuel; Haft, Jonathan W.; Cowger, Jennifer A.; Colvin, Monica; Aaronson, Keith D.; Pagani, Francis D.; Likosky, Donald S.
- Abstract
Key Points: Question: Is the presence of a heart transplant program associated with differential evaluation for transplant or transplant among patients who receive a left ventricular assist device (LVAD)? Findings: In this cohort study of 22 221 LVAD recipients from the Society of Thoracic Surgeons Intermacs database, patients receiving durable LVAD at centers that also performed heart transplants were significantly more likely to receive an LVAD as a bridge to transplant. In addition, patients treated at a combined LVAD/transplant center were more likely to receive a heart transplant in the subsequent 2 years. Meaning: The findings of this study suggest that the increased use of LVAD at centers that do not perform transplants has the potential to contribute to inequities in access to heart transplant, the gold-standard therapy for advanced heart failure. Importance: In 2020, the Centers for Medicare & Medicaid Services revised its national coverage determination, removing the requirement to obtain review from a Medicare-approved heart transplant center to implant a durable left ventricular assist device (LVAD) for bridge-to-transplant (BTT) intent at an LVAD-only center. The association between center-level transplant availability and access to heart transplant, the gold-standard therapy for advanced heart failure (HF), is unknown. Objective: To investigate the association of center transplant availability with LVAD implant strategies and subsequent heart transplant following LVAD implant before the Centers for Medicare & Medicaid Services policy change. Design, Setting, and Participants: A retrospective cohort study of the Society of Thoracic Surgeons Intermacs multicenter US registry database was conducted from April 1, 2012, to June 30, 2020. The population included patients with HF receiving a primary durable LVAD. Exposures: LVAD center transplant availability (LVAD/transplant vs LVAD only). Main Outcomes and Measures: The primary outcomes were implant strategy as BTT and subsequent transplant by 2 years. Covariates that might affect listing strategy and outcomes were included (eg, patient demographic characteristics, comorbidities) in multivariable models. Parameters for BTT listing were estimated using logistic regression with center-level random effects and for receipt of a transplant using a Cox proportional hazards regression model with death as a competing event. Results: The sample included 22 221 LVAD recipients with a median age of 59.0 (IQR, 50.0-67.0) years, of whom 17 420 (78.4%) were male and 3156 (14.2%) received implants at LVAD-only centers. Receiving an LVAD at an LVAD/transplant center was associated with a 79% increased adjusted odds of BTT LVAD designation (odds ratio, 1.79; 95% CI, 1.35-2.38; P <.001). The 2-year transplant rate following LVAD implant was 25.6% at LVAD/transplant centers and 11.9% at LVAD-only centers. There was an associated 33% increased rate of transplant at LVAD/transplant centers compared with LVAD-only centers (adjusted hazard ratio, 1.33; 95% CI, 1.17-1.51) with a similar hazard for death at 2 years (adjusted hazard ratio, 0.99; 95% CI, 0.90-1.08). Conclusions and Relevance: Receiving an LVAD at an LVAD-transplant center was associated with increased odds of BTT intent at implant and subsequent transplant receipt for patients at 2 years. The findings of this study suggest that Centers for Medicare & Medicaid Services policy change may have the unintended consequence of further increasing inequities in access to transplant among patients at LVAD-only centers. This cohort study examines access to heart transplant in patients at centers that implant left ventricular assist devices but do not perform transplants vs those at centers that provide both left ventricular assist devices and transplant.
- Subjects
HEART transplantation; HEALTH services accessibility; HEART assist devices; PATIENTS; RETROSPECTIVE studies; MANN Whitney U Test; CENTERS for Disease Control &; Prevention (U.S.); RESEARCH funding; POLICY sciences; LOGISTIC regression analysis; ODDS ratio; SENSITIVITY &; specificity (Statistics); TRANSPLANTATION of organs, tissues, etc.; PROPORTIONAL hazards models; HEART failure; COMORBIDITY
- Publication
JAMA Network Open, 2022, Vol 5, Issue 11, pe2240646
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2022.40646