Does the new heart transplant allocation policy encourage gaming by providers?

For the past two years, a different national allocation policy has been in effect in order to more fairly distribute hearts to those who require a life-saving transplant. People who need temporary mechanical pumps to support their hearts, like ECMO (extracorporeal membrane oxygenation) or a temporary LVAD (left ventricular assist device), are now given high preference.

These mechanical pumps are meant to be markers of illness severity, and thus, identify the sickest patients who would benefit most from a heart transplant.

However, a new research letter published by scientists at the Michigan Medicine Frankel Cardiovascular Center finds clinicians gave more patients these mechanical pumps once the new policy was in place than they had previously. That in turn moves more patients up the list for a transplant.

“Following the policy change, use of certain types of mechanical pumps increased up to five times,” says lead author Jessica Golbus, M.D., an advanced heart failure and heart transplant cardiology fellow at the Frankel CVC. “There was notably greater use of these pumps among men following the policy change, potentially giving them priority on the heart transplant list. This may reflect gaming of the system and has the potential to worsen outcomes such as gender disparities in heart transplantation.”

Co-author Monica Colvin, M.D., a heart failure and transplant cardiologist at the Frankel CVC, says transplant allocation policy changes are frequently accompanied by changes in listing practices in an effort to optimize listing strategies for individual patients.

“It remains to be seen whether this is a better strategy for transplant patients or whether this will create the same problems faced by the prior policy,” says Colvin, also a professor of internal medicine. “These types of analyses are essential in helping the community understand the challenges of policy development and its effect on patients and transplant centers, and will help to inform future policy."

Additional authors include Kashvi Gupta, MBBS, M.P.H.; Thomas Cascino, M.D., M.Sc.; Keith D. Aaronson, M.D., M.S.; Rajiv Saran, MBBS, M.D., M.S. and Brahmajee K. Nallamothu, M.D., M.P.H., all from the University of Michigan; with Dharam J. Kumbhani, M.D., from UT Southwestern Medical Center. Nallamothu is also affiliated with the Ann Arbor VA Medical Center, and Nallamothu, Cascino and Saran with Michigan Medicine’s Institute for Healthcare Policy and Innovation.

Paper cited: “Changes in Type of Temporary Mechanical Support Device Use Under the New Heart Allocation Policy.” Circulation. DOI: 10.1161/CIRCULATIONAHA.120.048844