Outcomes of Multiple Listing for Adult Heart Transplantation in the United States : Analysis of OPTN Data From 2000 to 2013

ObjectivesThis study sought to assess the association of multiple listing with waitlist outcomes and post–heart transplant (HT) survival.BackgroundHT candidates in the United States may register at multiple centers. Not all candidates have the resources and mobility needed for multiple listing; thus this policy may advantage wealthier and less sick patients.MethodsWe identified 33,928 adult candidates for a first single-organ HT between January 1, 2000 and December 31, 2013 in the Organ Procurement and Transplantation Network database.ResultsWe identified 679 multiple-listed (ML) candidates (2.0%) who were younger (median age, 53 years [interquartile range (IQR): 43 to 60 years] vs. 55 years [IQR: 45 to 61 years]; p < 0.0001), more often white (76.4% vs. 70.7%; p = 0.0010) and privately insured (65.5% vs. 56.3%; p < 0.0001), and lived in zip codes with higher median incomes (US$90,153 [IQR: US$25,471 to US$253,831] vs. US$68,986 [IQR: US$19,471 to US$219,702]; p = 0.0015). Likelihood of ML increased with the primary center’s median waiting time. ML candidates had lower initial priority (39.0% 1A or 1B vs. 55.1%; p < 0.0001) and predicted 90-day waitlist mortality (2.9% [IQR: 2.3% to 4.7%] vs. 3.6% [IQR: 2.3% to 6.0]%; p < 0.0001), but were frequently upgraded at secondary centers (58.2% 1A/1B; p < 0.0001 vs. ML primary listing). ML candidates had a higher HT rate (74.4% vs. 70.2%; p = 0.0196) and lower waitlist mortality (8.1% vs. 12.2%; p = 0.0011). Compared with a propensity-matched cohort, the relative ML HT rate was 3.02 (95% confidence interval: 2.59 to 3.52; p < 0.0001). There were no post-HT survival differences.ConclusionsMultiple listing is a rational response to organ shortage but may advantage patients with the means to participate rather than the most medically needy. The multiple-listing policy should be overturned.