Psychosocial risk assessment for heart transplantation: evaluating for bias and impact on posttransplant outcomes.

Abstract

Background: As pretransplant psychosocial risk (PSR) assessment is subjective, we investigated potential biases and the relationship between assessed PSR and posttransplant outcomes at our heart transplant center.

Methods: Four-hundred seventy-nine heart transplant (HT) recipients (05/2004-01/2021) had a pretransplant psychosocial evaluation, at which a social worker collected information on 25 characteristics and categorized the candidate's PSR for posttransplant death. Relationships between PSR and posttransplant outcomes (death, hospitalization, and rejection) were evaluated. Possible biases in PSR evaluation were examined by assessing the independent relationships between race, sex, psychosocial characteristics, additional socioeconomic characteristics imputed from US Census data, and the PSR categorization.

Results: Psychosocial risk was categorized as low (399), medium (57) or high²³. Medium or high-risk patients were younger and more likely to have psychosocial risk factors and live in less affluent neighborhoods. Race and sex were not found to influence the PSR categorization (both p=0.4). Neighborhood affluence score (OR 0.30, p=0.009) and family/social support (OR 500, p<0.001) were strongly and independently associated with PSR categorization, with less affluent patients and those without family/social support more likely to be medium or high-risk. Medium or high-risk categorization was not associated with increased mortality or hospitalizations after HT (p=0.5 and 0.3, respectively), but was associated with increased risk for experiencing rejection (HR 1.7, CI 1.02-2.90).

Conclusion: Medium- or high PSR was associated with a greater risk of rejection but not of hospitalization or death. There was no indication of race or sex bias in our program's preoperative psychosocial evaluations, but patient affluence may have influenced decision-making.