October 24, 2016
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System Flaws, Lack Of Insurance Bring Higher Death Rate Among Black Heart Patients

- Race matching among donors and recipients has no effect on survival
rates, study shows

Transplant surgeons at Johns Hopkins who have reviewed the medical
records of more than 20,000 heart transplant patients say that it is
not simply racial differences, but rather flaws in the health care
system, along with type of insurance and education levels, in
addition to biological factors, that are likely the causes of
disproportionately worse outcomes after heart transplantation in
African Americans.

In a report on the review to be published online June 1 in the Annals
of Thoracic Surgery, the Johns Hopkins team showed that race matching
donor hearts did nothing to extend the life in organ
recipients. Race matching is the practice of transplanting donor
hearts into patients of the same ethnic group. White donors would be
matched to white recipients, and the same would apply to blacks,
Hispanics or Asians.

"It does not matter whether a white, black, Hispanic or Asian donor
heart is transplanted into a patient of any other particular race,"
says senior study investigator and Johns Hopkins transplant surgeon
Ashish Shah, M.D. "Other factors must be the reason for any
differences in how well people do after transplantation, in
particular, why blacks have poorer outcomes."

In what is believed to be the largest and most detailed review of
medical records ever conducted on the subject, the Johns Hopkins team
combed 20,185 North American transplant patients' records. All
received a donor heart between 1997 and 2007.

Researchers found that 61 percent of heart recipients were race
matched (12,381). Among blacks, the death rate after five years was
the same, at 35 percent, whether donors and recipients were race
matched or not. The same was true among whites, at 26 percent, and
among Hispanics, at 28 percent. (Although trends appeared to be the
same for Asians, the number of transplants in Asians was not
statistically large enough to provide valid percentages.) Death or
survival rates were consistent for all timeframes, within a month,
three months, six months or a year after transplantation.

Study investigators found that race matching did little or nothing to
close the significant gap in blacks' survival rates. Whether or not
African Americans received a heart from a black donor, they faced a
46 percent higher chance of dying within 10 years after heart
transplantation. Specifically, 45.8 percent of blacks were alive and
well after 10 years, a rate 11.4 percent lower than for whites and
10.8 percent lower than for Hispanics.

Researchers say previous reports from nearly a dozen other academic
medical centers offered conflicting accounts about any potential
benefits from race matching. They say the latest study findings help
set the clinical record straight by pooling data from more than 140
hospitals licensed to perform heart transplants instead of relying on
data within individual hospitals.

Shah says the data "really prompts us to re-evaluate everything that
we do for our more vulnerable patients and to tailor our efforts to
the specific needs of each patient, especially African Americans, if
we hope to fix racial disparities in surviving heart transplantation.

"This problem is not just about biology or race, it is also about the
health system that supports our patients," says Shah, an associate
professor at the Johns Hopkins University School of Medicine and its
Heart and Vascular Institute.

He also notes that transplant patients can now put their minds at
ease that having a racially matched donor heart will not help or hurt them.

Lifting survival rates among blacks, who represent 15 percent of all
heart transplants, will, Shah says, require further study of which
life-extending factors may work, such as antirejection drug dosages,
more stringent follow-up to ensure patient compliance with drug
regimens and scheduled appointments, and education about early signs
of infection and possible organ rejection, including fever, shortness
of breath, fatigue, and swelling in the arms and legs.

Among the researchers' other key findings were that such problems
related to organ rejection within the first year, regardless of race,
were tied to insurance and education. Patients with public insurance,
specifically Medicaid, had a 30 percent higher risk of needing some
kind of antirejection treatment and a 39 percent higher risk of dying
than transplant recipients with private insurance. Transplant
recipients on Medicare did not fare well either, with a 12 percent
higher risk of dying than those with private insurance. Having a
college education lowered the overall group's likelihood of having a
rejection-related problem with their transplant by 12 percent.

In the study population, 20.5 percent of black transplant recipients
had Medicaid insurance compared to 8.8 percent of other races, and
fewer had private insurance (49.9 percent) compared to others (63.6
percent). The African-American group as a whole had a lower
percentage of college graduates than other races (at 40.6 percent and
50.3 percent).

Black recipients also had a higher degree of tissue antigen
mismatches with their transplanted hearts compared to other groups
(at 65.4 percent and 55.6 percent.) The better the match, Shah says,
the better the chances that immunosuppressive drugs will work over
the long term to prevent organ rejection. Hypertension and gender
mismatches, factors known to increase the chances of dying, were also
more widespread among African Americans.

Lead study investigator Jeremiah (Geoff) Allen, M.D., says a
combination of these circumstances in African Americans likely
contribute to their poorer outcomes.

Allen, a postdoctoral research fellow in cardiac surgery at Johns
Hopkins, says the team's next steps are to identify which combination
of factors stands out among those blacks who survive long term
post-transplant and those who do not. Some 45 percent of African
Americans with donated hearts, he notes, survived longer than 10 years.

An early identification system for those at higher risk of rejection
and death, and data on any differences in treatment protocols could
help narrow the survival gap for blacks, he says.

"This research is key to correcting the survival disparity in African
Americans in surviving heart transplantation, and helps us learn how
to take better care of some of our most high-risk transplant
recipients," says Allen.

The data used in the study came from the United Network for Organ
Sharing (UNOS), a national network that allocates donated organs
across the United States.

Funding for the study was supplied in part by the The Johns Hopkins
Hospital, with additional support from the U.S. Department of Health
and Human Services and its Health Resources and Service Administration.

In addition to Shah and Allen, other Johns Hopkins researchers
involved in this study were Eric Weiss, M.D., M.P.H.; George
Arnaoutakis, M.D.; Stuart Russell, M.D.; William A. Baumgartner,
M.D.; and John Conte, M.D.

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