UNOSpolicy change benefits high‐priority patients without harming those at low priority

The heart transplantation policy change (PC) has improved outcomes in high‐acuity (Old 1A, New 1–3) patients, but the effect on low‐priority (Old 1B/2, New 4–6) patients is unknown. We sought to determine if low‐priority patient outcomes were compromised by benefits to high‐priority patients by evaluating for interaction between PC and priority status (PS). We included adult first‐time heart transplant candidates and recipients from the UNOS registry during a 19‐month period before and after the PC. We compared clinical characteristics and performed competing risks and survival analyses stratified by PC and PS. There was a dependence of PC and PS on waitlist death/deterioration with an interaction sub‐distribution hazard ratio (adjusted sdHR) of 0.59 (0.45–0.78), p‐value < .001. There was a trend toward a benefit of PC on waitlist death/deterioration (adjusted sdHR: 0.86 [0.73–1.01]; p= .07) and an increase in heart transplantation (adjusted sdHR: 1.08 [1.02–1.14], p= .007) for low‐priority patients. There was no difference in 1‐year post‐transplant survival (log‐rank p= .22) when stratifying by PC and PS. PC did not negatively affect waitlisted or transplanted low‐priority patients. High‐priority, post‐PC patients had a targeted reduction in waitlist death/deterioration and did not come at the expense of worse post‐transplant survival. The updated heart allocation policy is associated with improved waitlist outcomes in high‐acuity patients, no significant difference in waitlist outcomes for low‐acuity patients, and no change in one‐year post‐transplant survival.