In their article, Patel et al1 discuss the regional and racial disparities over a 2-decade analysis of >33 000 adult heart transplant recipients in the United Network for Organ Sharing registry. Their findings reveal that regional variation in posttransplant survival is significant only among White recipients, while survival among Black, Hispanic, Asian, and “Other” recipients remains strikingly consistent across the United States. This work provides a timely and nuanced contribution to the literature on inequity in transplant outcomes, reframing how geography and race intersect in shaping posttransplant survival. In this retrospective analysis, White recipients in the South experienced higher mortality, whereas those in the West demonstrated significantly improved survival (adjusted hazard ratio, 0.77 95% confidence interval, 0.69-0.86; P < 0.001) when compared to the Northeast. No comparable geographic differences emerged among non-White recipients. These findings suggest that while regional disparities persist within majority populations, the outcomes for racial and ethnic minority groups are uniformly poor or constrained by systemic factors that transcend geography. Disparities and unequal access in the surgical management of advanced heart failure is nothing new. We have previously demonstrated that Black recipients experience higher risk-adjusted 1-y mortality, particularly at lower-performing centers (odds ratio, 1.37; P = 0.002).2 We have also found that African Americans bridged with left ventricular assist devices to transplantation had increased 5-y mortality compared with Whites (hazard ratio, 1.26; P = 0.003).3 Both studies emphasize that race-associated disparities persist even after adjustment for clinical and socioeconomic factors. In addition, we demonstrated that patients with lower education or government-based insurance were less likely to be transplanted at high-volume centers, where survival is superior (odds ratio, 1.21 for 1-y survival versus low-volume centers; P = 0.017).4 Collectively, these findings underscore the critical role of center performance, institutional access, and pretransplant socioeconomic context in shaping outcomes. When viewed against this backdrop, the results of this present article are both consistent and provocative: they extend the conversation from the level of individual centers to that of regional variation, revealing that racial inequities may be geographically invariant—a reflection of systemic inequities embedded within the broader fabric of U.S. healthcare. International data corroborates this interpretation. A national registry study in Denmark, a country with universal, publicly funded healthcare, found no significant race-based disparities in transplant access or outcomes once financial and structural barriers were removed.5 The Danish experience suggests that racial inequities observed in the United States are not inevitable consequences of biological or cultural differences but are instead products of structural features unique to U.S. healthcare, including variable insurance coverage, differential access to specialty centers, and persistent institutional bias. The findings by Patel et al,1 thus, align with a growing body of comparative international evidence demonstrating that universal systems mitigate—if not eliminate—race-associated variation in transplant care. The paradox that regional disparities appear only among White recipients challenges conventional assumptions. One interpretation is that regional healthcare infrastructure and socioeconomic conditions disproportionately benefit those already advantaged, leading to differential gains among White populations. In contrast, minority groups may experience uniformly constrained outcomes because of pervasive barriers—limited access, chronic under-insurance, implicit bias, and institutional racism—that persist independent of geography. We had previously proposed that improving access to high-performing centers would raise absolute survival but would not erase racial gaps.2 This article suggests a similar limitation applies to geography: regional optimization alone cannot produce equity if foundational structural barriers remain intact. Like most registry-based studies, this work is constrained by its retrospective nature. It does not include socioeconomic data and is limited in categorical racial definitions. Moreover, the predominance of White recipients (and their regional concentration in the South) may increase statistical power to detect regional effects in that subgroup. Nonetheless, the persistence of consistent mortality among minority recipients—despite varying local resources—points to a structural uniformity of inequity that warrants deeper exploration. In the words of Dr Martin Luther King Jr, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane”. Future research should integrate center-level performance metrics, social vulnerability indices, and patient-reported barriers to care. Only through such multilevel analyses can we begin to disentangle the overlapping effects of race, geography, and institutional structure.
Wessels et al. (Tue,) studied this question.