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US ranking for heart transplant candidates may prompt overtreatment
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Wide variation exists in practices of U.S. adult heart transplantation centers, and some centers may be overtreating hemodynamically stable patients, according to findings presented at the International Society for Heart & Lung Transplantation Annual Meeting and Scientific Sessions.
William F. Parker, MD, from the department of medicine at the University of Chicago, and colleagues analyzed 12,762 U.S. adults who were not in cardiogenic shock listed as candidates for heart transplantation between 2010 and 2015 by 108 centers participating in the Scientific Registry of Transplant Recipients. The results were simultaneously published in the Journal of the American College of Cardiology.
The researchers identified potential overtreatment as treatment of a patient who did not meet American Heart Association cardiogenic shock criteria with high-dose inotropes or an intra-aortic balloon pump. They also identified center-level variables linked to potential overtreatment.
Although potential overtreatment can be understood from the perspective of a heart transplantation physician, “widespread overtreatment is problematic for multiple reasons,” Parker and colleagues wrote in JACC. “First, it could lead to excess cost and unnecessary risk of therapy-related complications. Chronic inotrope therapy increases mortality in stable advanced heart failure and high-dose inotrope therapy is only indicated in cardiogenic shock. More importantly, overtreatment in heart transplantation unfairly elevates the status of less urgent candidates while truly urgent candidates die waiting (or perhaps are never listed).”
According to the researchers, 11.6% of the cohort was treated with high-dose inotropes or an intra-aortic balloon pump, meeting the definition for potential overtreatment.
When the centers were stratified by quartiles, wide variation was observed, according to the researchers. The rate of potential overtreatment in the bottom quartile was 2.1% vs. 27.6% in the top quartile (interquartile difference, 25.5%; 95% CI, 21-30).
After adjustment for differences in patient characteristics, the interquartile difference did not significantly change.
Centers with local competition, defined as having at least one competitor in the same organ procurement organization, had 50% greater odds of potentially overtreating patients (OR = 1.5; 95% CI, 1.07-2.11), Parker and colleagues found.
“There is meaningful variation in the treatment practices of adult heart transplantation centers,” Parker and colleagues wrote. “Heart transplantation centers that overtreat candidates have shorter waiting times and improved survival. Competition for transplantable hearts may drive overtreatment of hemodynamically stable heart transplant candidates. Overtreatment may compromise the fair and efficient allocation of scarce deceased donor hearts.”
In a related editorial in JACC, Larry A. Allen, MD, MHS, and Prateeti Khazanie, MD, MPH, from the division of cardiology and the Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, wrote that the study “is a timely contribution in an era as policies around heart transplant allocation are changing.”
They noted the United Network for Organ Sharing is changing its donor heart allocation policy from three strata to six, mandating broader geographic sharing of organs for the most high-risk patients and ordering that patients meet the AHA hemodynamic criteria for cardiogenic shock, and the study “supports efforts to revise our current heart allocation system to limit potential overtreatment based on subjective decisions to use inotropes, invasive monitoring and [intra-aortic balloon pump] support.” – by Erik Swain
References:
Parker WF, et al. Abstract 438. Presented at: International Society for Heart & Lung Transplantation Annual Meeting and Scientific Sessions; April 11-14, 2018; Nice, France.
Allen LA, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.02.031.
Parker WF, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.02.030.
Disclosures: Parker and Khazanie report no relevant financial disclosures. Another author reports he has received consultant fees from GE Healthcare and has served on the speakers bureau for Novartis and Relypsa. Allen reports he has consulted for Amgen, Boston Scientific, Janssen and Novartis.
Perspective
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Frank W. Smart, MD, FACC, FACP
The findings presented in this manuscript confirm that there is distinct difference in the way pre-transplant patients are treated, based on the local competition for donor hearts. This overtreatment disparity is not explained by patient characteristics or degree of illness.
I believe overtreatment is a bad thing. It is expensive and does not seem to alter the patient outcomes in a favorable manner. More importantly, if one center overtreats their patients in order to get more hearts, centers that are following appropriate care guidelines and their patients are disadvantaged and perform less transplants.
These findings do have implications for the UNOS allocation system, but this idea of gaming the system is not new; it is just newly published. We have been trying for more than 20 years to make rules of allocation that protect patients, are not too restrictive for physicians, and with these rules it is more difficult to game the system. I can say with a fairly high degree of certainty that there is no way to legislate morality. Gaming of the system will continue in some form.
The important message is, not only are patients being exposed to expensive and more risky therapies, but patients being treated by more ethical physicians are also endangered, because fewer hearts are available so that they might receive a transplant. A cost calculation for this type of overtreatment would be interesting.
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