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
1
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
(ALT) greater than 1,000 U/L
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
(ALT) greater than 1,000 U/L
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.
3
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.
6
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)
7
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.
8
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
9
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
10
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.
11
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.
12
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.
13
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
14
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.
15
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).
16
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
Working for Income 0.438 0.079 -4.600 0.000 0.308 0.623
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
College education 0.906 0.065 -1.360 0.173 0.787 1.044
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
17
Odds Ratio
Std. Err. z P>|z| [95% Conf. Interval]
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
History of Malignancy 1.042 0.134 0.320 0.748 0.810 1.341
History of Cardiac surgery 0.874 0.073 -1.630 0.104 0.742 1.028
Defibrillator in place 0.881 0.076 -1.470 0.141 0.745 1.043
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.
18
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
Std. Err. z P>|z| [95% Conf. Interval]
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
Working for Income 0.428 0.077 -4.730 0.000 0.301 0.608
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
College education 0.918 0.066 -1.180 0.237 0.797 1.058
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
19
Odds Ratio
Std. Err. z P>|z| [95% Conf. Interval]
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
History of Malignancy 1.046 0.134 0.350 0.725 0.813 1.346
History of Cardiac surgery 0.868 0.072 -1.710 0.088 0.737 1.021
Defibrillator in place 0.892 0.077 -1.330 0.183 0.754 1.056
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.
20
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.
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