title: Regional variation in the use of 1A status exceptions for pediatric heart transplant candidates: is this equitable?
abstract: The use of status exceptions (SE) was recently publicized as a strategy to reduce waitlist times for children awaiting heart transplant (HTx). The aim of this study was to assess SE use across UNOS regions and compare survival in patients listed using a SE to those listed by standard criteria. The OPTN database was queried for all pediatric patients listed for HTx (2000-2014). SE use was compared across UNOS regions. Survival curves were generated and compared using the log-rank test. 1A SE use is uncommon, being utilized in 108 of 4587 pediatric 1A listings (2.4%). There is significant variability in SE use across UNOS regions (0.7%-16.4% of 1A listings, P < .001). Waitlist survival is significantly higher in candidates listed using a 1A SE compared to those listed by standard criteria (P = .001) and is similar to 1B listings. Regional variation in 1A SE use has the potential to introduce bias into a system designed to be equitable. Waitlist survival in patients listed using a SE is similar to those listed status 1B, suggesting these patients may not require 1A status. Careful review of pediatric heart allocation policies is needed to optimize patient outcomes and ensure a fair and unbiased allocation system.
authors.affiliation: Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Godown
authors.affiliation: Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Meghann
authors.initials: M
authors.lastname: McKane
authors.affiliation: Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: Kari A
authors.initials: KA
authors.lastname: Wujcik
authors.affiliation: Pediatric Cardiothoracic Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: Bret A
authors.initials: BA
authors.lastname: Mettler
authors.affiliation: Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
authors.forename: Debra A
authors.initials: DA
authors.lastname: Dodd
mesh_terms: D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D005843:Geography; D000069576:Health Equity; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D008297:Male; D040841:Resource Allocation; D061665:Time-to-Treatment; D009927:Tissue and Organ Procurement / Q000379:methods*; D016896:Treatment Outcome; D014481:United States; D014850:Waiting Lists
keywords: heart transplant; organ allocation; pediatric; status exception; waitlist survival