Discrepancies in access and institutional risk tolerance in heart transplantation: A national open cohort study

Background: The impact of center volume on heart transplantation is widely recognized and serves as a benchmark for certification and reimbursement. Study aims: Study sociodemographic variables associated with access to high-volume centers and substantiate the importance of extending access to underserved populations. Methods: This study focused on adults undergoing heart transplantation between 2006 and 2015. Centers were clustered into terciles (>25, 14-25, or <14 transplants per year) and factors associated with receiving care in different terciles were identified through multinomial regression. Results: During the study period, 18 725 patients were transplanted at 145 centers. Younger age (<30 years) (P =.005), lower educational level (P <.001), and government-based insurance (P <.001) were associated to lower odds of receiving care at a high-volume center. These centers had higher risk recipients and accepted organs from higher risk donors, when compared to intermediate- and low-volume centers. Receiving care at high (odds ratio [OR], 1.212; P =.017) and intermediate-volume centers (OR, 1.304; P =.001) was associated with greater odds of 1-year survival when compared with low-volume centers. Conclusion: Social, demographic, and geographic factors affect access to high- and intermediate-volume centers. High-volume centers tolerate more risk while providing excellent survival. Awareness of this impact should prompt an extension of access to care for underserved patient populations.