Background: Socioeconomic and racial disparities in outcomes among patients with heart failure are well-documented. Whether such disparities exist among patients awaiting heart transplant (HT) is unclear. We aimed to characterize the associations of socioeconomic status (SES) and race with outcomes among patients listed for HT.
Methods: Patients listed for heart transplant between 1994 and 2014 were included (n = 64,276). SES indicators included insurance status, education, and neighborhood SES (nSES), measured by zip code using a composite index. The primary outcome was a composite of death or delisting and the secondary outcome was transplant. Multivariate analyses were employed to adjust for race, SES, comorbidity, and clinical severity at time of listing.
Results: Non-white race, low education, Medicare, Medicaid, and lower nSES (Figure 1) were associated with higher unadjusted risks of death or delisting. After adjustment, the associations with less than high school (HR=1.39) and college education (HR=0.93), Medicare (HR=1.22), Medicaid (HR=1.16), and lowest nSES quartile (HR=1.06) remained significant (p < 0.05; Figure 2). Risks associated with black race and low nSES decreased significantly over time. Adjusted incidence of transplant was significantly lower among blacks (HR = 0.90), but higher among other non-white patients.
Conclusions: Low SES is associated with poorer outcomes during HT listing, and there are racial disparities in the likelihood of transplant. Some of these disparities have narrowed over time. Further research is needed to identify the underlying cause of these disparities, which are not explained by measured clinical characteristics.