Access to Heart and Lung Transplantation for Minority Populations. Cedric Sheffield, MD

Transcription

1 Access to Heart and Lung Transplantation for Minority Populations Cedric Sheffield, MD

2 End Stage Heart Failure Magnitude of the Problem

3 CHF is America s Highest - Volume 700, , , , , , ,000 DRG Annual In-patient Volume 0 Congestive Heart Failure Simple Pneumonia and Pleurisy Cerebrovascular Disorders Angina Pectoris Psychoses The Advisory Board Co. 1994

4 Where Do We Need To Be? Jessup M, Brozena S. N Engl J Med 2003;348:

5 CHF - USA 2,000 Tx 5,000,000 Total 400,000/year 70,000 Class IV 300,000 Class III

6 Mortality expectation Mortality at One Year AIDS leukemia lung cancer Diagnosis pancreatic cancer end stage heart failure with optimal medical management

7 Survival (%) HEART TRANSPLANTATION ACTUARIAL SURVIVAL ( ) Half-life =9.1 years Conditional Half-life = 11.6 years N=52, Years Post-Transplantation

8 Number of Transplants HEART TRANSPLANTATION Non-US US % donors % donors * Numbers may be low due to incomplete reporting 978 * * 12% 9% 6% 3% Percent of Donors by Age

9 Heart Transplants in the 7,000 US Heart transplants have plateaued 6,000 5,000 4,000 Listed During Year Number of candidates listed continues to increase 3,000 2,000 1,000 Heart Transplants Died While Waiting Source: UNOS 1996 Annual Report

10 FUNCTIONAL STATUS 100% Heart (April 1994-Dec. 2000) 80% 60% 40% 20% 0% No Activity Limitations Performs with Assistance Total Assistance 1 Year 3 Years 5 Years

11 EMPLOYMENT STATUS 100% Heart (US Data: April 1994-Dec. 2000) 80% 60% 40% 20% 0% Working Full Time Working Part Time Not Working Retired 1 Year 3 Years 5 Years

12 Indications for Transplant Organ 1 st Diagnosis (%) 2 nd Diagnosis (%) 3 rd Diagnosis (%) Heart Dilated Myopathy Dilated Myopathy Congenital Defect Idiopathic (32%) Ischemic (32%) (7%) Lung COPD/Emphysema Pulmonary Cystic Fibrosis (Single and (30%) Fibrosis (28%) (16%) Double) Heart-Lung Pulmonary Hypertension Congenital Defect Eisenmenger s (29%) (13%) Syndrome (10%)

13 Transplant Trends Waiting list candidates as of today 112,173 Active waiting list candidates as of today 72,480 Transplants January - June ,969 Donors January - June ,924

14 Organ Transplants Performed Year Kidney Liver Heart Lung-Single Lung-Double Pancreas Intestine , , , , ,

15 Recipient Demographics Organ Kidney Liver Heart Lung Pancreas Intestine White 55% 70% 68% 84% 88% 69% Black Hispanic Asian Other

16 Organ Surgival by Ethnicity Heart White 92.8% 89.1% 76.6% 56.9% Black Hispanic Asian Other Unknown 33.6

17 Organ Surgival by Ethnicity Lungs White 92.2% 82.4% 50.6% 24.8% Black Hispanic Asian Other

18 Waiting Times by Ethnicity (Days) Heart Lung White Black Hispanic Asian Native American

19 Waiting List National Trends General flattening to growth of waiting list since 2007 most significant for kidney Most relative growth in lung waiting list More heart waiting list additions in 2010 than in any previous year

20 Waiting List Additions U.S.

21 Waiting List Registrations U.S.

22 Waiting List Registrations Region 3

23 Deceased and Living Donors U.S

24 Deceased and Living Donors Region

25 Deceased Donation Donors Recovered Region 3 Organs Recovered Organs Transplanted OTPD % Change 5.8% 6.9% 8.0% 2.1%

26 Deceased Donor Transplants U.S.

27 Deceased Donor Transplants Region 3

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32 Recipient Criteria Age 15 to 69 years Class IV CHF Class III CHF with limited life expectancy Intractable angina Recurrent ventricular tachycardia refractory to

33 Significant systemic disease Diabetes mellitis>mild end organ damage Malignancy <80% 5 year survival Amyloidosis with liver involvement Active infection Recent pulmonary infarction Active peptic ulcer disease Significant peripheral vascular disease

34 Significant systemic disease Smoking Noncompliance Inadequate Social support Inadequate Financial support

35 Transplant Cost Pre Procurement Hospital Physician Post Meds Total Kidney 16,700 67,500 92,700 17,500 47,400 17, ,000 Heart 34,200 94, ,400 50,800 99,700 22, ,700 Single Lung 7,500 53, ,600 27, , ,400 Double Lung 20,700 96, ,700 59, ,800 22, , US Organ and tissue transplant cost estimates

36 Case Studies Organ based or recipient based outcomes

37 Case Studies Pretransplant center barriers

38 Where Do We Need To Be? Jessup M, Brozena S. N Engl J Med 2003;348:

39 Case Studies Financial barriers age based

40 Aorta Diaphragm Heart HeartMate LVAD Skin line To drive console

41 Conclusions Greatest transplant benefit would incorporate eliminating barriers to transplant, improving access to donor organs, and improving posttransplant outcomes

42 Improved access to transplantation will have to involve increased organ donation. Barriers to transplantation will likely act also as obstacles to improved organ donation. Perhaps it time to discuss presumed donation consent. Trust in the health care system would have to strengthened for presumed organ donation to work.

43 Continued open minded data collection and analysis with interpretation and input by all affected groups is essential and necessary to avoid unintended consequences of good intentions.