(1034) Racial and Geographic Disparities in Utilization of Listing by Exception Among US Children Listed for Heart Transplantation

PurposePrevious studies suggest the use of waitlist exceptions may be lower in pediatric heart transplant (HT) candidates with low socioeconomic status. However, reports are limited to eras prior to 2016 when UNOS listing criteria revisions to standardize the exception process were implemented. We sought to determine whether there is evidence of racial or geographic disparities in utilization of waitlist exceptions during the current era.MethodsUNOS data were used to identify all US children <18 years of age at listing for isolated orthotopic HT from 2016-2022. Patients were categorized based on if initially listed by exception, creating 4 mutually exclusive categories (1A standard vs exception; 1B standard vs. exception). Center-specific variation in the use of listing exceptions was analyzed.ResultsOf 4,277 children listed since 2016, 60% were listed UNOS status 1A (53% standard vs. 7% exception), 22% status 1B (15% standard vs. 7% exception) while 19% were listed status 2. Common cardiac diagnoses among 1A and 1B exception candidates were CHD (34%), RCM (12%), HCM (9%), and HT graft failure (11%). While no racial group differential was evident in the use of 1A exceptions, Black candidates were 13% less likely than White candidates to be listed by 1B exception. Substantial center-based variation exists in the use of listing exceptions among 45 high-volume programs where 0 to 33% of patients were listed by exceptions (Figure) including 0 to 20% of patients by 1A exception. Patients listed by exception (1A and 1B) had lower waitlist mortality conferring a survival advantage.ConclusionIn the current era, there appears to be differential rates of listing pediatric HT candidates by 1B exception based on race, which may lead to racial disparities in outcome. Center-specific variation in the use of listing exceptions may also contribute to geographic disparities in outcome. Further research is needed to understand and address disparities in the use of exceptions by race and region. Previous studies suggest the use of waitlist exceptions may be lower in pediatric heart transplant (HT) candidates with low socioeconomic status. However, reports are limited to eras prior to 2016 when UNOS listing criteria revisions to standardize the exception process were implemented. We sought to determine whether there is evidence of racial or geographic disparities in utilization of waitlist exceptions during the current era. UNOS data were used to identify all US children <18 years of age at listing for isolated orthotopic HT from 2016-2022. Patients were categorized based on if initially listed by exception, creating 4 mutually exclusive categories (1A standard vs exception; 1B standard vs. exception). Center-specific variation in the use of listing exceptions was analyzed. Of 4,277 children listed since 2016, 60% were listed UNOS status 1A (53% standard vs. 7% exception), 22% status 1B (15% standard vs. 7% exception) while 19% were listed status 2. Common cardiac diagnoses among 1A and 1B exception candidates were CHD (34%), RCM (12%), HCM (9%), and HT graft failure (11%). While no racial group differential was evident in the use of 1A exceptions, Black candidates were 13% less likely than White candidates to be listed by 1B exception. Substantial center-based variation exists in the use of listing exceptions among 45 high-volume programs where 0 to 33% of patients were listed by exceptions (Figure) including 0 to 20% of patients by 1A exception. Patients listed by exception (1A and 1B) had lower waitlist mortality conferring a survival advantage. In the current era, there appears to be differential rates of listing pediatric HT candidates by 1B exception based on race, which may lead to racial disparities in outcome. Center-specific variation in the use of listing exceptions may also contribute to geographic disparities in outcome. Further research is needed to understand and address disparities in the use of exceptions by race and region.