Abstract
Background
Social determinants of health (SDH) such as poverty, unequal access to health care, and lack of education have recently been found to contribute to health inequities. In the field of heart transplantation, it is known that patients of color have a higher early mortality risk than white patients, even after taking differences in comorbidities into account. However, the role of SDH in predicting disease patterns and transplant outcomes has not been determined. The purpose of this study was to assess long-term heart transplantation success based on patients' SDH.
Methods
A retrospective analysis of 34,584 adult heart transplant recipients from 2004 to 2021 was performed using the Organ Procurement and Transplantation Network database. Established and modern SDH indices—including the Agency for Healthcare Research and Quality Index, the Area Deprivation Index, the Social Vulnerability Index , the Social Deprivation Index, and the Crime Risk Index—were evaluated. A survival analysis using the Kaplan-Meier method assessed the indices' association with overall graft survival or failure. A temporal decomposition model was used to identify overlapping phases of graft survival. Multivariable clustered Cox regression, LASSO and random forest models were used to determine the association of these indices with post-transplantation risk of graft failure.
Results
On average, patients falling into the lower quartile across different SDH indices had a 20% increased risk of graft failure. After accounting for recipient and donor biological factors and comorbidities, recipients' indices remained statistically significant. Individual sociodemographic variables were highly predictive of graft failure across different hazard intervals. Recipients' SDH indices were most predictive throughout the constant and late post-transplantation phases. On the other hand, donor SDH indices were less significant across all intervals.
Conclusion
To improve survival outcomes, a collaborative effort to counsel and support disadvantaged transplant recipients should be considered.