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Shock Criteria Description: The full detailed shock requirements are listed in below in Online

Table 1. We identified candidates potentially overtreated by the shock requirement according to

previously published methodology which we review here.1 First, we identified candidates subject

to the shock criteria based on the listed indication on the Status 1A justification forms. We then

classified candidates based as in shock or not based on cardiac index and pulmonary capillary

wedge pressure according to the guidance in the policy for hemodynamic values obtained in

various circulatory support scenarios.2 Because there are relatively few VA-ECMO and

percutaneous mechanical circulatory support candidates (<50 a year) and these candidates often

have missing hemodynamic data, these candidates were conservatively characterized as “in

shock” and excluded.1 We used justification form hemodynamics for high-dose/multiple inotrope

candidates and transplant candidate registration (TCR) hemodynamics for IABP patients. We

used inotrope doses available from the justification form to apply the minimum dose criteria to

the high dose inotrope group. Body weight, height, and cardiac output were used to calculate

cardiac index for each patient using the DuBois formula for body surface area.3 For candidates

with missing hemodynamic data or supported with multiple support therapies, we considered

them as in shock at the time of listing. Because blood pressure readings were only available for

candidates treated with inotropes, we conservatively did not apply this portion of the criteria. For

candidates listed with IABP with hemodynamics measured while receiving IABP support, the

policy does not offer specific guidance. Therefore, we decided a priori to categorize IABP

candidates on mechanical support as in shock if the cardiac index was <2.2 L/min/m2 on IABP

support. We based this threshold on the criteria outlined for high-dose/multiple inotrope

candidates on mechanical support at the time of cardiac index measurement, “[cardiac index] less

than 2.2 L/min/m2 for candidates with … mechanical support”.2

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Online Table 1. The Detailed Cardiogenic Shock Requirement by Therapy Type

Candidate Groups Status Initial Listing Criteria

Veno-Arterial Extracorporeal

Membrane Oxygenation(VA ECMO)

1

A candidate’s transplant program may assign a candidate to adult status 1 if the candidate is admitted to the transplant hospital that registered the candidate on the waiting list, and is supported by VA ECMO for cardiogenic shock as evidenced by either of the following:

Within 7 days prior to VA ECMO support, all of the following are true within one 24 hour period:

a. Systolic blood pressure less than 90 mmHgb. Cardiac index less than 1.8 L/min/m2 if the candidate is not

supported by inotropes or less than 2.0 L/min/m2 if the candidate is supported by at least one inotrope

c. Pulmonary capillary wedge pressure greater than 15 mmHg If hemodynamic measurements could not be obtained within 7 days

prior to VA ECMO support, at least one of the following is true within 24 hours prior to VA ECMO support:

o CPR was performed on the candidateo Systolic blood pressure less than 70 mm Hgo Arterial lactate greater than 4 mmol/lo Aspartate transaminase (AST) or alanine transaminase

(ALT) greater than 1,000 U/L

Percutaneous Endovascular Mechanical Circulatory

Support Device

2

A candidate’s transplant program may assign a candidate to adult status 2 if the candidate is admitted to the transplant hospital that registered the candidate on the waiting list, and is supported by a percutaneous endovascular mechanical circulatory support device without an oxygenator for cardiogenic shock as evidenced by either of the following:

Within 7 days prior to MCS support, all of the following are true within one 24 hour period:

a. Systolic blood pressure less than 90 mm Hgb. Cardiac index less than 1.8 L/min/m2 if the candidate is not

supported by inotropes or less than 2.0 L/min/m2 if the candidate is supported by inotropes

c. Pulmonary capillary wedge pressure greater than 15 mmHg If hemodynamic measurements could not be obtained within 7 days

prior to MCS support, at least one of the following is true within 24 hours prior to MCS support:

o CPR was performed on the candidateo Systolic blood pressure less than 70 mm Hgo Arterial lactate greater than 4 mmol/l o Aspartate transaminase (AST) or alanine transaminase


2

Intra-Aortic Balloon Pump 2

A candidate’s transplant program may assign a candidate to adult status 2 if the candidate is admitted to the transplant hospital that registered the candidate on the waiting list, and is supported by an IABP for cardiogenic shock as evidenced by either of the following:

Within 7 days prior to IABP support, all of the following are true within one 24 hour period:

d. Systolic blood pressure less than 90 mm Hge. Cardiac index less than 1.8 L/min/m2 if the candidate is not

supported by inotropes or less than 2.0 L/min/m2 if the candidate is supported by inotropes

f. Pulmonary capillary wedge pressure greater than 15 mm Hg If hemodynamic measurements could not be obtained within 7 days

prior to IABP support, at least one of the following is true within 24 hours prior to IABP support:

o CPR was performed on the candidateo Systolic blood pressure less than 70 mm Hgo Arterial lactate greater than 4 mmol/l o Aspartate transaminase (AST) or alanine transaminase


Multiple Inotropes or a Single High Dose Inotrope and Hemodynamic Monitoring

3

A candidate’s transplant program may assign a candidate to adult status 3 if the candidate is admitted to the hospital that registered the candidate on the waiting list, and within 7 days prior to inotrope administration or while on inotropes meets all of the following:

1. Has one of the following: Invasive pulmonary artery catheter Daily hemodynamic monitoring to measure cardiac output and

left ventricular filling pressures2. Is in cardiogenic shock, as evidenced by all of the following within

one 24 hour period:a. Systolic blood pressure less than 90 mm Hgb. Pulmonary Capillary Wedge Pressure greater than 15 mmHgc. Cardiac index of either:

Less than 1.8 L/min/m2 for candidates without inotropic or mechanical support within 7 days prior to inotrope administration

Less than 2.2 L/min/m2 for candidates with inotropic or mechanical support

3. Is supported by one of the following: A continuous infusion of at least one high-dose intravenous

inotrope:o Dobutamine greater than or equal to 7.5 mcg/kg/mino Milrinone greater than or equal to 0.50 mcg/kg/mino Epinephrine greater than or equal to 0.02 mcg/kg/min

A continuous infusion of at least two intravenous inotropes:o Dobutamine greater than or equal to 3 mcg/kg/mino Milrinone greater than or equal to 0.25 mcg/kg/mino Epinephrine greater than or equal to 0.01 mcg/kg/mino Dopamine greater than or equal to 3 mcg/kg/min

mcg/kg/min

Table constructed (with permission) directly from the policy details in Modify adult heart allocation 2016 2nd round - OPTN. https://optn.transplant.hrsa.gov/media/2265/exec_policynotice_20170828_clarifications_adult_heart_allocation.pdf. Accessed March 15, 2018.

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https://optn.transplant.hrsa.gov/media/2265/exec_policynotice_20170828_clarifications_adult_heart_allocation.pdf

https://optn.transplant.hrsa.gov/media/2265/exec_policynotice_20170828_clarifications_adult_heart_allocation.pdf

Online Figure 1. Kaplan Meier Estimated Survival from Time of Listing at Top and Bottom Quartile Centers (stratified by initial listing Status)

Overall

Overall survival from listing for all Statuses shown above. In a cox model with shared frailty by center, the interaction term between initial listing Status and quartile was not significant (p = 0.73). This implies that the effect of being listed at a top center was similar for listing Statuses.

4

Because potential overtreatment of non-cardiogenic shock candidates was rare in the bottom quartile, there were very few non-cardiogenic shock status 1A candidates in the bottom quartile.

5

See overall survival rates for the entire all non-cardiogenic shock candidates in Table 2. Overall survival from time of listing (not censored by transplant) is displayed, stratified by initial listing Status.

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Detailed Statistical Methods

Risk-Standardized Rates

Let yij be the treatment outcome for the ith candidate listed at the jth center and yij = 0 indicate

appropriate treatment and yij = 1 indicate potentially inappropriate treatment. The first multilevel

regression model we estimated was

logit (Pr ( y ij=1 ))=α j+β0+β∗X ij

where β0 is a constant, X ij is a vector of candidate characteristics, and α j N (0 , τ2) is a normally

distributed error term (random center level intercept). Adding a third level for OPO did not result

in significant improvement in the model (p = 0.315 by likelihood ratio test). The full model

results are displayed in Online Table 2.

Adjusted probabilities of overtreatment for each candidate were calculated from the results of the

model

P̂ij=logit−1¿)

where α̂ j is the empirical Bayes (mean) prediction of the random intercept. We then calculated

the expected overtreatment rate for each candidate

Eij=logit−1¿)

This expected overtreatment rate is the model predicted probability of overtreatment for the ith

patient if the patient was listed at the “mean” center, or the center with α j=0. The standardized

overtreatment rate for center j is then

R j=∑

iP̂ij

∑i

Eij

∗mean(P j)

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where mean ( P j )is the mean of the center rates. We chose to standardize with the mean center rate

instead of the grand mean overtreatment rate to avoid skewing towards large centers. This

standardized rate provides an index to compare different centers, accounting for differences in

candidate mix at each center.

Center and OPO level predictors of potential overtreatment

We then estimated a model with OPO level fixed effects

logit (Pr ( y ij=1 ))=α j+β0+β∗X ij+γ∗Z ij

where Zij is a vector of OPO level variables, calculated individually for each ith candidate listed

at the jth center. We used backward selection with a retention criterion of p < 0.1 to remove OPO

level variables until we arrived at the final model (found in Online Table 5). Adding a third

level (random OPO intercept) did not result in a significant improvement in the model (p = 0.248

by likelihood ratio test). We did not use this model to produce standardized overtreatment rates.

Finally, we repeated the backward selection process with center-level variables forcing retention

of candidate variables and previously significant OPO-level variables and ended up with the

model found in Online Table 6.

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Online Table 2. Model 1. Multilevel logistic regression results for outcome of potential overtreatment with candidate level predictor variables

Odds Ratio Std. Err. z P>|z| [95% Conf. Interval]Age at Listing 0.994 0.003 -1.660 0.097 0.988 1.001Height (cm) 0.998 0.007 -0.280 0.783 0.984 1.012Weight (kg) 0.991 0.006 -1.370 0.171 0.979 1.004

Blood Type AB 0.995 0.153 -0.030 0.972 0.736 1.345B 1.095 0.115 0.870 0.385 0.892 1.345O 0.770 0.061 -3.320 0.001 0.660 0.899

Male Gender 1.172 0.124 1.500 0.134 0.953 1.441

BMI 25–29 0.751 0.094 -2.290 0.022 0.589 0.95930–34 0.785 0.163 -1.170 0.244 0.523 1.179≥35 0.653 0.210 -1.320 0.185 0.348 1.227

Functional Status 10% 33.964 27.266 4.390 0.000 7.042 163.81520% 12.255 9.406 3.270 0.001 2.723 55.15730% 4.854 3.741 2.050 0.040 1.072 21.98840% 0.469 0.367 -0.970 0.334 0.101 2.17550% 1.022 0.790 0.030 0.977 0.225 4.65260% 0.527 0.409 -0.820 0.410 0.115 2.41670% 0.555 0.429 -0.760 0.446 0.122 2.52880% 0.385 0.303 -1.210 0.226 0.082 1.80590% 0.248 0.227 -1.520 0.129 0.041 1.499unknown 2.792 2.188 1.310 0.190 0.601 12.972

Working for Income 0.442 0.079 -4.550 0.000 0.311 0.629

Race Black 1.171 0.108 1.710 0.087 0.978 1.403Hispanic 1.029 0.132 0.220 0.825 0.800 1.323Other 1.068 0.175 0.400 0.690 0.774 1.473

College education 0.902 0.065 -1.440 0.150 0.783 1.038

Payor Medicaid 0.921 0.106 -0.710 0.475 0.736 1.154Medicare 0.779 0.065 -2.980 0.003 0.661 0.918Other 1.057 0.195 0.300 0.765 0.736 1.516

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Odds Ratio Std. Err. z P>|z| [95% Conf. Interval]Diagnosis

Ischemic cardiomyopathy 0.977 0.089 -0.250 0.801 0.817 1.169

Restrictive cardiomyopathy 0.918 0.109 -0.720 0.471 0.727 1.159

Other 0.524 0.071 -4.760 0.000 0.401 0.683

Diabetes 1.019 0.082 0.230 0.817 0.870 1.194

Renal Function 30-–mL/min/1.73 m2 1.070 0.082 0.880 0.379 0.920 1.243<30 mL/min/1.73 m2 1.350 0.215 1.880 0.060 0.988 1.843on dialysis 0.967 0.193 -0.170 0.867 0.654 1.431

Smoking history 0.884 0.065 -1.670 0.095 0.765 1.022

History of CVA 0.887 0.138 -0.770 0.439 0.654 1.202

History of Malignancy 1.034 0.133 0.260 0.794 0.804 1.330

History of Cardiac surgery 0.869 0.072 -1.690 0.091 0.739 1.023

Defibrillator in place 0.880 0.075 -1.490 0.136 0.744 1.041

Constant 9.097 9.080 2.210 0.027 1.286 64.343Variance of center level

random intercept 1.263 0.221 0.896 1.781

Base case is patient with blood type A, female, BMI < 25, functional status 100%, white, private insurance, GFR ≥ 60 mL/min/1.73 m2, with dilated cardiomyopathy. In the model explained variance was 35%. Residual ICC was 0.2775 with 95% CI (0.2141–0.3512). The residual center ICC after adjustment for candidate variables was 28%, indicating that 28% of the variation in overtreatment could be attributed to center of listing. To put this number in perspective, a typical physician ICC for a clinical decision like cancer screening is around 10%.4–6

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Comment on significant candidate level covariates

Significant candidate level covariates that predicted potential overtreatment included blood type

O, larger weight, functional status, work history, payor, and cardiac diagnosis. Functional status

had a strong negative relationship to potential overtreatment as expected. The negative

association of blood group O and larger body habitus can be explained by the have long wait

times these candidates experience for suitable donor hearts. Blood group O hearts (universal

donor) are not only allocated to Status IA group O patients but also to other Status IA blood

group candidates. Smaller transplant candidates can accommodate a wider range of recipient size

and tend to be transplanted sooner. Therefore, given the universally long wait times regardless of

management strategy, the incentive to overtreat these candidates is likely lower. Finally, patients

with private insurance were more likely to be overtreated than patients with Medicare.

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Online Table 3. Risk-standardized overtreatment rate quartiles

Standardized Overtreatment Quartile Bottom quartile 2nd quartile 3rd quartile Top quartile

(n = 27) (n = 27) (n = 27) (n = 27)Center standardized rate range <7.3% 7.4-11.5% 11.6-17.5% ≥17.6%

Mean Rate (95% CI)Standardized overtreatment rate 4.6 (4.0–5.3) 9.3 (8.6–9.9) 14.3 (13.4–15.2) 27.8 (24.1–31.5)

Unadjusted overtreatment rate 3.2 (2.5–3.9) 6.4 (4.9–8.0) 11.2 (8.8–13.5) 26.3 (20.4–31.9)

Unadjusted overtreatment quartile Number of Centers (%)

Bottom 18 (67) 9 (33) 0 (0) 0 (0)

2nd 8 (30) 12 (44) 6 (22) 1 (4)3rd 1 (4) 4 (15) 16 (59) 5 (19)

Top 0 (0) 2 (7) 5 (19) 21 (78)

Mean rates calculated as grand mean of each quartile, i.e., weighted at candidate level.

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Online Figure 2. Geographic Variation of Risk-Standardized Potential Overtreatment Rates

National variation in the risk-standardized rates of treatment of heart transplant candidates with

balloon pumps or high-dose inotropes despite the absence of cardiogenic shock are displayed.

Rates are aggregated at the Organ Procurement Organization (OPO) level, the first local level of

organ allocation in the US. Colors correspond to quartiles of potential overtreatment.

Comparison to Figure 1 in demonstrates that most OPOs are in the same quartile of unadjusted

and risk-standardized rates.

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Online Table 4: Balancing table of candidate covariates before and after nearest neighbor 1-1 propensity score matching

Raw Matched -----------------------------------------

Total Candidates = 5,548 6,406 Top Quartile Candidates = 3,203 3,203

Bottom Quartile Candidates = 2,345 3,203 -----------------------------------------

Standardized Differences Variance ratioRaw Sample Matched Raw Sample Matched

Age at Listing 0.130 0.034 0.946 1.067Height (cm) -0.057 -0.007 1.069 1.031Weight (kg) -0.130 -0.044 0.938 1.007

Blood TypeAB -0.008 0.032 0.968 1.146B 0.019 0.012 1.039 1.024O 0.008 0.002 1.002 1.001

Male Gender -0.040 0.018 1.042 0.983

BMI 25–29 0.034 0.047 1.020 1.02930–34 -0.081 -0.105 0.908 0.886≥35 -0.068 0.016 0.813 1.054

Functional Status20% 0.211 -0.052 1.341 0.94830% 0.045 0.053 1.141 1.17140% 0.203 0.042 1.878 1.11250% 0.006 0.011 1.014 1.02860% -0.056 0.004 0.891 1.00870% -0.356 0.010 0.575 1.02380% -0.149 -0.033 0.666 0.90390% 0.018 0.057 1.126 1.498100% 0.019 0.006 1.463 1.111unknown 0.247 -0.029 6.503 0.887

Working for Income -0.098 -0.029 0.790 0.927

RaceBlack -0.005 0.002 0.993 1.002Hispanic 0.019 0.008 1.052 1.021Other 0.026 0.025 1.107 1.104

College education -0.087 -0.067 1.010 1.007

PayorMedicaid -0.074 0.017 0.849 1.042Medicare -0.070 -0.010 0.952 0.992Other -0.016 -0.029 0.929 0.877

Diagnosis

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Ischemic cardiomyopathy

0.069 -0.022 1.047 0.987

Restrictive cardiomyopathy

-0.041 0.030 0.900 1.085

Other -0.083 0.021 0.839 1.050

Diabetes 0.026 0.039 1.024 1.037

Renal Function30–59 mL/min/1.73 m2

-0.050 -0.010 0.980 0.996

<30 mL/min/1.73 m2 0.024 -0.018 1.115 0.928on dialysis 0.043 0.009 1.268 1.046

Smoking history -0.113 0.022 0.978 1.007

History of CVA -0.016 -0.029 0.931 0.882

History of Malignancy -0.042 0.022 0.878 1.076

History of Cardiac surgery

-0.007 0.010 0.995 1.006

Defibrillator in place -0.160 0.024 1.273 0.971Base case is patient with blood type A, female, BMI < 25, functional status 10%, white, private insurance, GFR ≥ 60 mL/min/1.73 m2, with dilated cardiomyopathy. All standardized differences were less than 0.1 (with the exception of BMI 30–34), indicating adequate balancing in the propensity score matched cohorts. Candidates in top quartile centers were matched to similar bottom quartile candidates to estimate the average effect of being listed at a top quartile center. Some bottom quartile candidates were used multiple times by the matching algorithm.

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Online Figure 3. Balance plot for candidate functional status before and after propensity score matching

Before matching (left), top quartile centers had candidates with worse functional status than bottom quartile centers. After matching (right), the selected bottom quartile candidates had a similar distribution of functional status as the top quartile candidates (see Online Table 4 for standardized differences).

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Online Table 5. Model 2: Multilevel logistic regression results for outcome of potential overtreatment with candidate level and OPO level predictor variables.

Odds Ratio

Std. Err. z P>|z| [95% Conf. Interval]

Center level variablesAge at Listing 0.994 0.003 -1.680 0.092 0.988 1.001Height (cm) 0.998 0.007 -0.290 0.771 0.984 1.012Weight (kg) 0.992 0.006 -1.350 0.176 0.980 1.004

Blood Type

AB 0.988 0.153 -0.080 0.939 0.730 1.338B 1.094 0.115 0.860 0.392 0.891 1.344O 0.771 0.061 -3.310 0.001 0.661 0.899

Male Gender 1.169 0.124 1.480 0.139 0.951 1.438

BMI

25–29 0.746 0.093 -2.340 0.019 0.585 0.95330–34 0.777 0.162 -1.210 0.224 0.517 1.168≥35 0.643 0.207 -1.370 0.170 0.342 1.208

Functional Status

10% 34.880 27.915 4.440 0.000 7.267 167.42320% 12.595 9.632 3.310 0.001 2.813 56.38730% 4.983 3.827 2.090 0.037 1.106 22.45340% 0.477 0.372 -0.950 0.343 0.103 2.20250% 1.064 0.820 0.080 0.936 0.235 4.81660% 0.551 0.426 -0.770 0.441 0.121 2.51270% 0.575 0.444 -0.720 0.473 0.127 2.60880% 0.388 0.305 -1.200 0.229 0.083 1.81490% 0.239 0.219 -1.560 0.119 0.040 1.444

unknown 2.920 2.282 1.370 0.170 0.631 13.510


Race Black 1.178 0.109 1.780 0.076 0.983 1.412

Hispanic 1.035 0.133 0.270 0.789 0.805 1.331Other 1.070 0.177 0.410 0.683 0.774 1.478


Payor

Medicaid 0.918 0.105 -0.750 0.454 0.733 1.149Medicare 0.779 0.066 -2.970 0.003 0.660 0.919

Other 1.076 0.199 0.390 0.694 0.748 1.547

Diagnosis Ischemic cardiomyopathy 0.982 0.090 -0.200 0.841 0.820 1.175

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Odds Ratio


Restrictive cardiomyopathy 0.909 0.108 -0.800 0.423 0.719 1.148Other Diagnosis 0.529 0.072 -4.680 0.000 0.405 0.690

Diabetes 1.023 0.083 0.280 0.777 0.873 1.199

Renal Function

30–59 mL/min/1.73 m2 1.067 0.082 0.840 0.401 0.917 1.240<30 mL/min/1.73 m2 1.345 0.214 1.860 0.063 0.984 1.838

on dialysis 0.973 0.195 -0.140 0.890 0.656 1.442

Smoking history 0.881 0.065 -1.710 0.088 0.762 1.019

History of CVA 0.887 0.138 -0.770 0.440 0.654 1.203




OPO level variables

Proportion of Status 1A transplants (per 10%) 1.065 0.036 1.840 0.066 0.996 1.138

3+ centers in OPO(base 1–2 centers) 1.505 0.258 2.380 0.017 1.075 2.106

Median 1A time to

transplant(base 19–63 days)

<19 days 1.432 0.134 3.840 0.000 1.192 1.720≥64 days 1.219 0.136 1.770 0.076 0.979 1.516

Constant 4.489 4.567 1.480 0.140 0.611 32.973

Variance of center level random intercept 1.214 0.217 0.855 1.723

The model explained variance proportion is 37%. The residual ICC is 0.270 with 95% CI (0.206–0.344). Base case is candidate with blood type A, female, BMI < 25, functional status 100%, white, private insurance, GFR ≥ 60 mL/min/1.73 m2, with dilated cardiomyopathy.

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Online Table 6. Model 3: Multilevel logistic regression results for outcome of potential overtreatment with candidate level, OPO level, and center level predictor variables

Odds Ratio


Center level variablesAge at Listing 0.994 0.003 -1.750 0.080 0.988 1.001Height (cm) 0.997 0.007 -0.380 0.705 0.983 1.011Weight (kg) 0.992 0.006 -1.270 0.205 0.980 1.004

Blood Type

AB 0.986 0.152 -0.090 0.929 0.729 1.335B 1.084 0.114 0.770 0.442 0.882 1.332O 0.765 0.060 -3.400 0.001 0.656 0.893

Male Gender 1.168 0.123 1.470 0.142 0.949 1.436

BMI

25–29 0.754 0.094 -2.270 0.023 0.590 0.96330–34 0.780 0.162 -1.190 0.233 0.519 1.173≥35 0.626 0.201 -1.460 0.146 0.333 1.176

Functional Status

10% 32.415 26.014 4.330 0.000 6.724 156.26220% 11.349 8.712 3.160 0.002 2.521 51.09630% 4.456 3.435 1.940 0.053 0.983 20.19240% 0.421 0.329 -1.110 0.268 0.091 1.95150% 0.976 0.754 -0.030 0.975 0.215 4.44060% 0.515 0.400 -0.850 0.393 0.113 2.36170% 0.523 0.405 -0.840 0.403 0.115 2.38480% 0.342 0.270 -1.360 0.174 0.073 1.60590% 0.210 0.193 -1.700 0.090 0.035 1.276

unknown 2.663 2.087 1.250 0.211 0.573 12.374


Race Black 1.191 0.110 1.900 0.058 0.994 1.427

Hispanic 1.017 0.130 0.130 0.893 0.791 1.308Other 1.067 0.176 0.390 0.694 0.772 1.474


Payor

Medicaid 0.921 0.106 -0.720 0.472 0.735 1.153Medicare 0.783 0.066 -2.910 0.004 0.664 0.923

Other 1.040 0.193 0.210 0.833 0.723 1.496

Diagnosis Ischemic cardiomyopathy 0.995 0.091 -0.050 0.957 0.831 1.191

Restrictive cardiomyopathy 0.915 0.109 -0.740 0.457 0.725 1.155

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Odds Ratio


Other Diagnosis 0.542 0.074 -4.510 0.000 0.415 0.707

Diabetes 1.018 0.082 0.210 0.830 0.868 1.193

Renal Function 30–59 mL/min/1.73 m2 1.071 0.082 0.890 0.375 0.921 1.245<30 mL/min/1.73 m2 1.328 0.211 1.780 0.075 0.972 1.814on dialysis 0.971 0.195 -0.140 0.885 0.656 1.439

Smoking history 0.885 0.066 -1.640 0.101 0.765 1.024

History of CVA 0.887 0.138 -0.770 0.440 0.654 1.203




OPO level variables

Proportion of Status 1A transplants (per 10%) 1.024 0.036 0.680 0.496 0.956 1.098

3+ centers in OPO(base 1–2 centers) 1.452 0.228 2.380 0.017 1.068 1.974

Median 1A time to transplant

(base 19–63 days)

<19 days 1.253 0.120 2.360 0.018 1.039 1.513≥64 days 1.307 0.147 2.380 0.017 1.048 1.629

Center practice variables

Proportion of candidates listed at Status 1A

(per 10%) 1.199 0.047 4.680 0.000 1.111 1.294

30-day transplant rate (per 10%) 1.186 0.053 3.810 0.000 1.086 1.294

Constant 3.199 3.238 1.150 0.251 0.440 23.266Variance of center level

random intercept 0.747 0.155 0.497 1.122

The explained variance proportion is 42%. Residual ICC is 0.185 with 95% CI (0.131–0.254). Base case is candidate with blood type A, female, BMI < 25, functional status 100%, white, private insurance, GFR ≥ 60 mL/min/1.73 m2, with dilated cardiomyopathy.

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References for Supplement:1. Parker WF, Garrity ER, Fedson S, Churpek MM. Potential impact of a shock requirement on

adult heart allocation. J Heart Lung Transplant. 2017;0(0). doi:10.1016/j.healun.2017.05.015.

2. Modify adult heart allocation 2016 2nd round - OPTN. https://optn.transplant.hrsa.gov/governance/public-comment/modify-adult-heart-allocation-2016-2nd-round/. Accessed December 15, 2016.

3. Dubois D, Dubois E. Clinical calorimetry. A formula to estimate the approximate surface area if height and weight be known. Arch Intern Med. 1916:863–871.

4. Singal AK, Lin Y-L, Kuo Y-F, Riall T, Goodwin JS. Primary care physicians and disparities in colorectal cancer screening in the elderly. Health Serv Res. 2013;48(1):95–113. doi:10.1111/j.1475-6773.2012.01433.x.

5. Hoffman KE, Niu J, Shen Y, et al. Physician Variation in Management of Low-Risk Prostate Cancer: A Population-Based Cohort Study. JAMA Intern Med. 2014;174(9):1450–1459. doi:10.1001/jamainternmed.2014.3021.

6. Tan A, Kuo Y-F, Elting LS, Goodwin JS. Refining physician quality indicators for screening mammography in older women: distinguishing appropriate use from overuse. J Am Geriatr Soc. 2013;61(3):380–387. doi:10.1111/jgs.12151.

7. Snijders TAB, Bosker RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. SAGE; 2011.

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