Abstract Body (Do not enter title and authors here): Background:
Heart transplantation remains the optimal treatment for advanced heart failure. The 2018 policy change for heart transplant allocation introduced more objective physiological criteria for listing and changed the geographical distribution of organs in an effort to minimize waitlist mortality and reduce inequities in transplantation rates. It is not known whether racial disparities vary across Organ Procurement and Transplantation Network (OPTN) regions since the policy change.

Objective:
To evaluate racial disparities in heart transplant allocations in the post-2018 policy era.

Methods:
Using data from the Organ Procurement and Transplantation Network (OPTN), we analyzed racial/ethnic transplant allocations compared to waitlist demographics. We compared the proportion of transplants received by Black and White patients using risk ratios defined as:

(Black patients on waitlist/(Black patients on waitlist + Black patients transplanted in 2023)) / (White patients on waitlist/(White patients on waitlist + White patients transplanted in 2023))

A ratio equal to 1 indicates equal transplant rates in Black and White patients. A ratio greater than 1 suggests inequities (i.e., Black patients transplanted at lower rates relative to White patients).

Results
In 2023, 4,545 heart transplants were performed. The overall risk ratio comparing rates of Black patients on the waitlist to White patients on the waitlist was 1.11 (95% CI: 1.05-1.18), indicating that Black patients are transplanted at lower rates than White patients. The most significant disparities were seen in some of the Northeastern regions of the United States, specifically in Regions 2 and 9. A waiting list times analysis of the current waitlist did not show any significant differences between racial groups.

Conclusion
Racial disparities persist in heart transplant allocations despite policy changes aimed at improving equity. Variation between regions suggests these disparities are complex and multifaceted, possibly requiring local structural changes in addition to policy changes to rectify.