medwireNews: US research suggests that transplant teams are less likely to accept the first offer for a heart when caring for a man than a woman, with physicians also less likely to accept the first offer for Black patients than their White counterparts.
“These disparities existed after adjusting for the pertinent donor-, patient-, and offer-level characteristics that may impact the decision to accept a donor heart,” Khadijah Breathett (Indiana University School of Medicine, Indianapolis) and colleagues point out in JAMA.
“This finding suggests racial and gender bias as a potential contributor to the organ acceptance decision-making process.”
The researchers analyzed data from the United Network for Organ Sharing from 2018 to 2023 for 14,890 non-Hispanic White and Black heart transplant candidates. Overall, 73.6% were men and 26.4% were women, and 69.1% were White while 30.9% were Black.
The median age of the candidates was 53–59 years and most had a waiting list status of 4 out of a possible 6 (where a status of 1 indicates greatest severity of illness). All candidate groups had a median calculated panel reactive antibody level below 2% and a median pulmonary vascular resistance of no more than 3 mmHg x min/L. White men had the highest proportion of previous nonventricular assist device cardiac surgeries, at 43.7%, and Black men had the highest proportion of ventricular assist devices, at 34.3%.
In all, 13,760 donor hearts became available and 1,59,177 donor heart offers were made.
The median number of offers per patient was six but this varied among the different candidate groups: Black men received a median of 11 offers, Black women received seven, White men received nine, and White women received five.
An offer was accepted for 72.5% of the candidates, with first offers accepted in 11.4% of cases. White women had the highest acceptance rate for first offers, at 17.5%, followed by Black women, at 14.0%, White men, at 10.3%, and Black men, at 7.9%.
After considering patient-, donor-, and offer-related factors, the researchers found that Black candidates were a significant 24% less likely to accept the first heart offered than White candidates, and this trend persisted until the 16th offer.
When sex was taken into account, women were a significant 53% more likely to accept their first heart offer than men. This difference remained significant in favor of women for the first six offers, by which time most of the women had accepted an offer, the authors say.
The investigators comment that the differences “could be generated from a false security that Black patients and/or men can wait longer for a better offer or from greater fear of a bad outcome with selecting an ‘imperfect’ donor for a particular race and/or gender.”
They say: “Further investigation is needed of the hospital-level decision-making process. Changes in the decision pathway to accept a donor organ are needed.”
In an accompanying editorial, Paul Heidenreich and colleagues, from Stanford University School of Medicine in Palo Alto, California, USA, note that the current study was conducted after a revision to the US donor heart allocation system to make “organs more widely available and with preference for the sickest patients.”
They say that “[t]he new heart transplant allocation system has successfully increased transplant access, but the effect on equity is less clear.” Breathett and team “have identified a concerning but poorly understood difference in race- and sex-based transplant practice,” they stress.
Heidenreich and colleagues conclude: “While the registry data used in these analyses have been crucial for exposing disparities, it is time to fund more detailed analyses of these practices, including in-depth studies of social determinants of health and race-based differences in immune responses in the setting of organ transplantation.”
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JAMA 2024; doi:10.1001/jama.2024.0065
JAMA 2024; doi:10.1001/jama.2024.0812