Global strategies to improve equitable access to heart and lung transplantation- ISHLT Consortium Report

Abstract

Background

Many inequities exist in the global access of heart and lung transplantation. Few studies have identified global strategies to implement equitable access to heart or lung transplantation.

Methods

Members of the International Society for Heart and Lung Transplantation (ISHLT) developed a consortium to identify strategic priorities to improve global access to heart and lung transplantation according to the Capability, Opportunity, Motivation- Behavior Change Wheel Model (COM-B/ BCW), an implementation science framework. Initial workshops were held at the ISHLT Scientific Sessions and refined with follow-up focus group meetings of consortium members from 2025 through 2026.

Results

Focus 1 was to improve quality of transplant data for access and outcomes; prioritized behavior included: 1) improving collection of social determinants of health, race, and ethnicity data, and 2) collecting data on patients referred but not listed. Focus 2 was to improve transplant access to diverse racial and ethnic populations; prioritized behavior included: 1) increasing transparency regarding candidacy and allocation, and 2) improving awareness regarding diverse patient and community needs for transplant consideration. Focus 3 was to improve access with patient-centered approaches; prioritized behavior included: individualizing a comprehensive patient assessment and plan. Focus 4 was to develop transplant programs in under-resourced countries; prioritized behaviors included: 1) developing a national or regional heart and lung transplant infrastructure and workforce plan, and 2) identifying and designating transplant capable centers as pilot hubs or consortium nodes.

Conclusions

An ISHLT consortium developed and prioritized strategies for behavior change to improve global access to heart and lung transplantation. These strategies may form the basis of global quality improvement and implementation research studies for transplantation equity.

Non-standard Abbreviations (frequent use)

APEASE

Acceptability, Practicability, Effectiveness, Affordability, Side-effects, Equity

COM-B/BCW

Capability, Opportunity, Motivation- Behavior Change Wheel Model

SDOH

social determinants of health

Introduction

International disparities are matrixed in the access of heart and lung transplantations. There are major transplant disparities related to race, ethnicity, socioeconomic factors, and sex within countries.1, 2 In the U.S., populations with the greatest risk of heart failure (HF), particularly Black patients, may have allocation decisions influenced by bias3, 4 and have the lowest rates of being listed5, 6 and receiving a heart transplantation.7, 8 Similarly, lung transplant referrals and evaluations have been less likely to occur for individuals from minoritized racial and ethnic groups and for those with less socioeconomic means.9, 10 Socioeconomic factors have also contributed to disparities in the access and outcomes of advanced HF care in multiple countries in Europe, including those with universal healthcare.¹¹

Access to transplants vary by country and continent, often in relation to a country’s gross domestic product.11, 12 Across the globe, over 50% of the heart or lung transplantations occur in North America.13, 14 Among the Global Burden of Disease regions, high-income North America has the highest heart transplantation rate per million population (12.6 per million), and rates are zero or less than one in Central Latin America, Caribbean, all regions of Africa, Asia, and Oceania.¹⁵ Rate patterns for lung transplantation are similar to heart transplantation (peaking 9.3 per million in high-income North America) with the exception of all regions of Latin America also having rates of less than one per million population.¹⁵ While the prevalence of HF is higher among countries with higher sociodemographic indices, wealthier countries,¹⁶ the magnitude of differences in the transplantation rate reflect disparate access to transplantation. Whereas, sociodemographic indices correlate with risk factors for global chronic respiratory diseases,¹⁷ which is relevant for lung transplantation.

The vast international disparities for individual heart and lung transplantation are well documented, but interventions to address the most pressing factors are more elusive. The International Society for Heart and Lung Transplantation (ISHLT) convened a workshop for the 2024 Scientific Sessions in Prague, Czech Republic to address barriers to global equity in heart and lung transplantation, with speakers representing all continents but Antarctica. In 2025, the Boston workshop for the ISHLT Scientific Sessions was streamlined to develop strategies that address the most concerning foci, which were preselected by the chairs and speakers. Foci included: 1) improving quality of transplant data for access and outcomes, 2) improving transplant access to diverse racial and ethnic populations, 3) improving access with patient-centered approaches, and 4) developing transplant programs in under-resourced countries. An implementation science framework for developing evidence-based strategies to change behavior, the Capability Opportunity Motivation (COM-B)/Behavior Change Wheel (BCW), was selected to guide the consortium workshop and subsequent refinement meetings.

Thus, our objectives are to provide the most prioritized, evidence-based strategies to improve global access to heart or lung transplantation. In this consortium manuscript, we describe the following COM-B/ BCW steps for each of the four foci: defining the problem in behavioral terms, prioritizing target behavior, specifying selected targeted behavior, COM-B behaviors to change, behavioral diagnosis, and existing evidence-based interventions that meet behavioral diagnoses. This provides practical direction to guide strategy implementation in hospitals and organizations that direct heart and lung transplantation care across much of the globe.

Methods

COM-B/BCW

COM-B/BCW is an established implementation science framework to guide the development of strategies to change behavior at an individual or system level.¹⁸ COM-B/BCW identifies how to optimize use of an effective intervention by enhancing stimuli for behavior change based on ability at an individual-level (psychological and physical capacity to perform a behavior), aligning external factors to promote change (physical or environmental opportunity and social or cultural opportunities for change), and motivation for change (reflective/analytical and automatic/visceral response).¹⁸ COM-B/BCW strategies are aligned to the stimuli requiring change, which were based upon extensive review of psychological and behavioral literature.18, 19

COM-B/BCW traditional steps include using focus groups or assessing literature to 1) define the problem using behavioral terms (describe ideal behavior and who performs it), 2) prioritize target behavior (according to impact, likelihood of successful change, potential to address other related issues indirectly, ease of measuring success), 3) specifying targeted behavior (according to who, what, when, where, how, etc.), 4) identifying what needs to change for targeted behavior to occur according to one’s capability, opportunity, and motivation, 5) selecting intervention functions according to behavior needs for COM-B forming a behavioral diagnosis, 6) selecting policy categories, 7) selecting behavior change techniques or strategies, and 8) specifying mode of delivery.20, 21

We applied COM-B/BCW in a step-wise fashion during the 2025 ISHLT scientific session workshop. Brief 10-minute lectures were provided on a single continent experience for each of the four foci: 1) improving quality of transplant data for access and outcomes, 2) improving transplant access to diverse racial and ethnic populations, 3) improving access with patient-centered approaches, and 4) developing transplant programs in under-resourced countries to spur conversation prior to launching into focus groups for the foci.

Participants

Workshop participation was open to individuals during early registration for ISHLT scientific sessions and additional personal invitations were made to ensure adequate global representation at the workshop. Participants included cardiovascular and pulmonary transplant clinicians, social and clinical scientists, and clinical section leaders with some having overlapping roles (N=23). Attendees were made aware of the plans to report findings in a consortium paper for ISHLT. No institutional review was required as this was a consortium workshop for ISHLT.

Developing consensus

Consensus development occurred through an in-person ISHLT workshop followed by virtual focus group meetings and iterative written review. Participants were assigned to one of four focus groups according to interest/expertise and appropriate numerical spread of individuals. A chair (KB) provided training on COM-B/BCW to focus group leaders (JC, SL, AAG, HKK) prior to the initial workshop and between focus group meetings. The focus groups were directed through COM-B/BCW steps and provided opportunities to share their findings and gain additional feedback from other focus groups throughout the workshop moderated by chairs (KB, LP). Steps 1 through 3 were completed in-person for each focus. Additional steps were completed virtually over the course of several months for each focus group. Step 5 was selected using Acceptability, Practicability, Effectiveness, Affordability, (limited) Side-effects, Equity (APEASE) criteria.²⁰ Steps 6 and 7 were combined to include literature searches to identify existing evidence-based strategies that address behavioral diagnoses. Step 8 was not necessary for this consortium.

Notes and repetitive ideas or themes were collected via completion of paper and electronic tables during the consortium workshop and subsequent meetings, which assisted with confirmability of findings. Triangulation was obtained by assessing for agreement with responses across focus groups, focus team leaders, and chairs. Chairs and focus group leaders met between focus group meetings and refined strategies virtually and via e-mail iteratively until there was agreement, also confirming credibility of original ideas and transferability across different centers and countries.

Results

Improving quality of transplant data for access and outcomes

Defining the problem in behavioral terms

The quality of data related to transplant access and outcomes is limited by inconsistent and incomplete documentation practices at the provider and center level. Transplant teams do not consistently collect structured data on social determinants of health (SDOH), race, and ethnicity during evaluation, and there is minimal systematic capture of information for patients who are evaluated but not listed for transplant.²² These gaps reflect behavioral challenges in prioritization, workflow integration, and standardization. Although providers have the capability to collect these data, competing clinical demands, limited resources, and lack of clear expectations result in variable implementation, ultimately hindering the identification and mitigation of disparities in transplant access and outcomes.23, 24

Prioritizing target behavior

Two target behaviors were prioritized based on their potential to significantly improve data completeness and equity in transplantation. First, improving the collection of SDOH, race, and ethnicity data during transplant evaluation is essential, as these variables are critical for identifying disparities in access, care delivery, and outcomes. Second, systematically collecting data on patients who are evaluated but not listed for transplant addresses a major gap in current data systems, as this population represents a key point where inequities may arise but remain poorly characterized.

These behaviors were selected because they are feasible within existing clinical workflows, align with current data collection practices, and have high potential impact. By focusing on earlier stages in the transplant process, these interventions allow for more timely identification of barriers and enable targeted strategies to improve equitable access to transplantation.

Specifying selected target behavior

1. Improve collection of SDOH, race, and ethnicity data: This behavior involves ensuring that transplant coordinators and providers consistently collect standardized and complete information on patients’ SDOH, granular collection of race and ethnicity, at the time of transplant evaluation. This includes integrating structured data fields into routine workflows, minimizing missing data, and promoting accurate and patient-centered documentation practices.

2. Collect data on patients referred but not listed: This behavior involves systematically documenting all patients who undergo transplant referral and evaluation but are not listed, including clear documentation of reasons for non-listing. This requires embedding standardized data fields into existing systems, ensuring consistent completion across centers, and incorporating this step as a routine component of the evaluation process rather than an optional task.

COM-B behaviors to change

1. Improve collection of SDOH, race, and ethnicity data: Psychological capability is generally adequate, as transplant teams are experienced in collecting clinical data; however, increasing awareness of the importance of SDOH data is necessary (Table 1, Figure 1a). Physical opportunity is a key barrier, as collecting additional data increases workload in already resource-constrained settings and may require workflow redesign, integration into electronic health records and potential allocation of additional resources and staffing as well as ongoing education to the team.

Table 1.

COM-B Changes to Improve Quality of Transplant Data for Access and Outcomes

COM-B Components	Improve collection of SDOH, race, and ethnicity data	Collect data from patient referred but not listed for transplant
Physical capability	Staff may need training on how to access, interpret, and enter SDOH/race/ethnicity data	•Develop new form for logging referrals •Develop data entry skills for referral patients
Psychological capability	•Knowledge of why these data matter for equity •Understanding of standardized tools and classifications	Gain knowledge on the importance of understanding which patients were not evaluated and why
Physical opportunity	Electronic health records and ISHLT data portals must support structured entry fields	•Need additional coordinator or data entry support. •Documenting referrals will add a significant amount of work to already-busy providers.
Social opportunity	Peer and organizational norms should support and expect equity-focused data collection	Need agreement across centers that this data collection is worthwhile.
Reflective motivation	•Belief that this data improves outcomes and fairness •Commitment to equity and access goals	•Centers feel a sense of responsibility for patients waitlisted. We need to develop a similar sense for patients referred. •Centers already feel stretched thin with documentation. They need to believe they have the bandwidth for this additional task. •We anticipate collecting data will document uncomfortable socio-economic disparities. Some may be unavoidable given the resource-intensive nature of solid organ transplant and limitations of national social safety nets, but identifying modifiable disparities is of key importance.
Automatic motivation	•Inclusion of these steps into routine workflows •Institutional reinforcement and accountability	•Include these steps into routine workflow •Increase institutional reinforcement and accountability.
Behavioral Diagnosis	Physical Opportunity: Restructuring the environment for collecting data with new tools, definitions, and increased importance (e.g. electronic health record–based interventions)Reflective Motivation: Framing the value of data collection as essential to equity in transplant outcomes as a form of persuasion and incentivization for collecting data	Physical Opportunity: creating system level approaches to capture data through environmental restructuring and enabling the changes Reflective Motivation: accountability for all evaluated patients through persuasion and incentivization for data capture (e.g. audit and feedback)

Figure 1.

COM-B Improving Quality of Transplant Data for Access and Outcomes. 1a. Improve collection of SDOH, race, ethnicity data; 1b. Collect data on patients referred but not listed.

Social opportunity plays an important role, as adoption depends on shared recognition across centers that standardized SDOH data collection is valuable. Institutional norms and peer practices can influence uptake. Reflective motivation is critical, as providers must perceive the effort as meaningful and aligned with improving patient-centered care and equity. Automatic motivation can be enhanced by embedding structured fields into electronic systems and reinforcing completion through feedback and accountability mechanisms.

2. Collect data on patients referred but not listed: Psychological capability is similarly sufficient, though awareness of the importance of capturing data on non-listed patients needs to be strengthened (Table 1, Figure 1b). Physical opportunity is a barrier due to the absence of established workflows, additional documentation burden, and lack of follow-up of those patients that are referred to the center but not followed by the center.

Social opportunity requires consensus across centers that capturing these data is a priority. Reflective motivation is particularly important, as centers must expand their sense of responsibility beyond waitlisted patients to include all evaluated individuals. Concerns about workload may limit engagement unless the value of these data is clearly communicated. Automatic motivation can be supported by integrating documentation into routine workflows and reinforcing compliance through institutional expectations and performance feedback.

Behavioral diagnosis

1. Improve collection of SDOH, race, ethnicity data: The behavioral diagnosis prioritizes physical opportunity and reflective motivation. Addressing resource needs through workflow integration and system-level support is affordable and practical when aligned with existing infrastructure. This requires restructuring the environment for data collection and employing news tools within electronic health records to easily capture data. Interventions targeting motivation such as persuasion and incentivization, are effective and acceptable, as they align with providers’ commitment to high-quality care. Governing bodies can incentivize programs by providing risk adjustments on outcomes and promotional information on centers that appropriately collect data and secondarily offer resources as appropriate for SDOH needs. These approaches are safe and promote equity by enabling more accurate identification of disparities.

2. Collect data on patients referred but not listed: Similarly, physical opportunity and reflective motivation are central. Establishing systems to capture data on non-listed patients is practical and can be integrated into existing workflows as partial data is already collected and will require establishing a system for follow-up and evaluation of outcomes. This restructuring will be enhanced through enabling the process with slots for this data into governing body tracking records. Motivation may be enhanced by fostering accountability for all evaluated patients through persuasion with audit and feedback nudges and promotional incentivization of programs that are appropriately collecting data. These strategies are effective, safe, and promote equity by illuminating barriers to access that are currently underrecognized.

Existing evidence-based interventions

Recent guidelines and evidence-based initiatives strongly support improving SDOH data collection in transplantation. The 2025 recommendations from the American Society for Transplantation and Cellular Therapy (ASTCT) advocate for standardized, pre-transplant SDOH assessments conducted by trained team members, with an emphasis on validated and longitudinal data collection approaches.²⁵ Similarly, established guidelines such as Kidney Disease Improving Global Outcomes (KDIGO) (2020) and American Association for the Study of Liver Disease/AST (2025) incorporate SDOH domains—including social support, financial resources, and living conditions—within routine psychosocial evaluations, reinforcing their clinical relevance.26, 27

Validated tools such as the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) and the Psychosocial Assessment Tool (PAT 2.0) provide structured approaches to capturing these data, with studies demonstrating a high prevalence of identified SDOH risk factors among transplant populations.²⁸ In parallel, system-level innovations—such as the Consortium for the Holistic Assessment of Risk in Transplant (CHART) Common Data Model—demonstrate the feasibility of extracting and standardizing SDOH data from electronic health records across centers.²⁹ Despite these advances, national data sources remain incomplete, underscoring the need for standardized, workflow-integrated interventions to improve data capture and support equitable transplant care.²⁴

Evidence-based strategies such as audit and feedback as a form of persuasion, and electronic health record–based interventions (e.g., mandatory fields and prompts as a form of environmental restructuring) can improve data completeness by embedding these practices into routine workflows and reinforcing accountability.

Improving transplant access to diverse racial and ethnic populations

Defining the problem in behavioral terms

Heart and lung transplantation are guideline-indicated therapies for individuals with advanced, end-stage cardiopulmonary disease, however disparate access2, 30, 31, 32, 33, 34 to minoritized racial and ethnic groups has been continuously observed. Inequity in transplant access contributes to premature death in racial and ethnic groups, and this disparity is widened by higher disease burden coupled to social determinants and structural factors that perpetuate less access to preventative and comprehensive cardiopulmonary care prior to transplant consideration. In the universal context of transplantation as a public trust, anchored by fairness and ethical stewardship, equitable access to all racial and ethnic groups must be an articulated, measured, and accountable goal of international heart and lung transplant networks to maintain ‘good faith’ donation and buy-in from the participating public.³⁵ To successfully develop strategies to change behaviors to impact disparate transplant access for minoritized racial and ethnic groups, five core needs were identified, including 1) improving transparency regarding candidacy and allocation, 2) defining disparities in access and allocation, 3) promoting awareness regarding diverse patient and community needs pertaining to transplant consideration, 4) eliminating use of race-based equations, corrections, or proxies in organ allocation scores, and 5) targeted funding for equity-focused interventions addressing disparate heart and lung transplant access.

It is important to recognize that each of these core needs will require behavior change from multiple transplant community stakeholders in addition to transplant clinicians and potential recipients. For example, improving transparency regarding candidacy and allocation will involve policymaking bodies, certification entities, professional societies, transplant centers and clinicians, community allies, and potential recipients. Defining disparities across international transplant networks will require assessment of each diverse system with input from local government, community and civic leaders, professional societies with investment in transplant justice, health systems with clinicians and expert academia, and individual patients. Behavior change to promote awareness of diverse patient and community needs in relation to and in preparation for transplant consideration will require engagement of community liaisons, civic leaders, health systems and clinician leaders, and patients and their care partners.

Prioritizing target behavior

Increasing transparency regarding transplant candidacy and allocation across communities and amongst clinicians was thought to have high impact and high positive spillover effects in improving transplant access in diverse communities. Ease of behavior change adoption and measurement across stakeholders was thought to be more difficult, and in need of validated, mixed-methods for assessment of the behavior change intervention. Improved awareness regarding diverse patient and community needs was also considered to be of high impact to this subgroup of discussants, citing examples from their respective institutional experience of limited clinician awareness of social and structural determinants of health, including cultural experiences and practices that impact health behaviors, or limited depth of knowledge of the diverse populations served by an individual transplant center and their respective community needs. Similarly, increased awareness of diverse patient and community needs was prioritized as a possible high impact opportunity for behavior change given role of community activation and advocacy in eliminating premature death from advanced cardiopulmonary disease amongst minoritized communities.

Defining disparities was considered essential to improving transplant access for minoritized racial and ethnic groups across systems, recognizing that U.S. or North American definitions of racial and ethnic disparities may differ from definitions for individual transplant networks across Europe, Latin America, Australia, Africa, and Asia. Hence, the defining relevant racial and ethnic disparities and instituting data collection for equitable transplant access should be a mandatory practice that transcends geographic constraints based on the core tenant of a public trust. Participants also noted that defining disparity will be inextricably tied to improving transparency regarding candidacy and allocation. In addition, discussants concluded that describing disparity should be the starting point, and not the conclusion of this work, citing examples of extensive research describing transplant disparities across organ systems that has not evolved into actionable strategies and solutions.

Focused attention was also given to emerging evidence on race-neutral evaluation of lung function in spirometry and kidney function with glomerular filtration rate to better evaluate severity of end-organ disease in Black patients;36, 37 there was discussion on the role this plays in more timely referral for transplant therapies, transplant access, and organ allocation using allocation scores that factor in race-neutral metrics, as opposed to historical raced-based corrections with poor justification by evidence. Prioritization of funding for equity-based interventions targeting equitable access across racial and ethnic groups was also thought to be of high impact and easily demonstrable, but anticipated difficulty was high in transplant networks overseen by entities which may restrict priorities.

Specifying selected target behavior

1. Increased transparency regarding transplant candidacy and allocation: Primary stakeholders to engage in behavior change regarding transparency in candidacy and allocation include government and regulatory agencies, policymakers, transplant centers and networks, and associated clinicians. This behavior change would best be performed in coordination with health systems and referral networks. The fundamental mode to increase transparency would be via public reporting, standardization of objective psychosocial assessments, and effective community engagement.

Oversight and governing bodies of heart and lung transplantation would require the physical ability to publicly report consensus level organ transplant criteria and absolute barriers in forums accessible to diverse communities. This is to lessen gatekeeper effects from lack of clarity of suitable candidates for referring providers or activated patients for self-referral to transplant centers. Governing bodies would also need the physical ability to publicly report aggregate demographics per transplant center regarding those evaluated, listed, and transplanted across demographic groups. Cost of transplant and financing, citizenship and immigration status considerations, psychosocial assessment best practices, and resources for help with timely referral and second opinion processes were also considered focus areas in which transplant governing bodies should provide governing standards to transplant centers and a central repository of these center standards as a patient-facing resources, publicly accessible to improve transparency. Physical opportunities to change environments include leveraging mixed media direct to communities, across transplant networks, from both health systems and governing bodies.

Health systems and transplant centers would require the physical capability to define and disseminate their center-specific criteria for heart and lung transplant to referring centers and clinicians and broadly to surrounding communities. There should be delineation of center specific barriers and what interventions, timeframes, and outcomes are required to transition candidacy status. For example, if active cigarettes use is a barrier to transplantation, then the program should state such, and provide clarity that patients would need 6 months abstinence as evidenced by negative monthly nicotine screens and written behavioral contract for abstinence post-transplant. Policies of individual centers that adhere to the requirements of the central governing body that are publicly accessible, may lessen concerns about ad lib policy adherence and provide more accountability to the public trust in ensuring equitable access across diverse patients. Psychological capability will also be required of selection committee members and clinicians for development of skills in bias recognition and reduction. Furthermore, clinician capability would need to expand regarding knowledge and application of SDOH, pertinent to transplant evaluation and listing. Standardization of candidate review and decision-making processes with public-facing description of the objective criteria used will also improve transparency for candidacy decisions as also suggested by the pediatric community.³⁸ This may have the spillover effect of amplifying multidisciplinary voices in a transplant evaluation, improving patient and caregiver advocacy, to minimize default ‘group-think’ often dominated by the loudest, or most empowered voices for decision-making. Social opportunities identified pertained to social influences for positive behavior change, including recognition programs for equitable achievement in transplant access based on surrounding communities and cardiopulmonary disease burden, and program-share collaborations involving local improvements in diversifying transplant access. Additional social influences identified included local and national political influences and transplant programmatic competition, which were considered as both enablers and threats to the targeted behavior change. Reflective motivation was articulated as vested interest in all individuals with end-stage cardiorespiratory disease to know requirements for transplant candidacy, “in their hometown” or closest center and to maximize fairness in consideration of their candidacy for transplantation.

To improve transparency in candidacy and allocation, the behavioral diagnosis included physical capability and psychological capability across stakeholders. Physical capability correlates to primary intervention functions of training and enablement. Psychological capability correlates to intervention functions of education, training, and enablement. As such, intervention functions prioritized for this behavior change impact policy categories including service provision, legislative and regulatory actions, fiscal policies, guidelines, and social planning. Using enablement and associated policy categories of guidelines and regulatory action, physical capability can be enhanced by public reporting of center specific transplant candidacy criteria, the decision-making process, and published demographic data on number of patients evaluated, listed, and eventually transplanted. Transplant centers typically already have public facing websites and are already reporting patient specific data to regulatory bodies. Hence, addition of these equity-focused interventions with public accessibility would leverage current infrastructure, are practical, and likely acceptable and effective. Utilizing training and associated policy category of service provision, psychological capability can be improved by implementation of a bias reduction training requirement and multidisciplinary objective decision-making processes for transplant committee members. As there are already standardized training and regulatory requirements for members of these committees, addition of these interventions or psychological capability will likely be of limited additional cost and are practical.

2. Improved awareness regarding diverse patient and community needs for transplant consideration: Primary stakeholders involved in improving awareness for diverse patient and community needs include local transplant centers, organ procurement networks, health systems with referral networks, and community health advocates and civic and community leadership. This target behavior requires creating cross talk between the transplant centers and surrounding diverse communities. In theory, community liaisons should be selected and engaged in advisory board action for transplant centers organ procurement networks and regulatory bodies. In practice, however, this does not necessarily translate to improved engagement of diverse communities with the least access to transplant. Regulatory requirements for sustained community partnership with transplant centers, in the interest of a public trust, should involve a stakeholder advisory board with diverse, representative community members who advise on and address community and social needs that may impact candidacy. Decentralization from the grounds of the primary transplant center may maximize community engagement in executing this target behavior change.

COM-B behaviors to change

Assessment of and intervention upon social needs is a class I recommendation by the HF guidelines for all patients with symptomatic HF (Table 2, Figures 2a and 2b). However, there is currently no consistent assessment of social needs, or targeted interventions, nor is there any consistent monitoring of these needs as barriers to HT for patients not under active evaluation. For patients already under transplant evaluation, psychosocial assessments are required to proceed, though these are not standardized or reported broadly. Furthermore, interventions on psychosocial needs are not required, reported, or recommended. As such, physical capability can be enhanced by utilizing governing bodies with active registries to create or adapt a data resource registry for all patients under active transplant evaluation to include psychosocial assessment, social needs, and planned or documented intervention on social needs, as needed for candidacy. There may be increased social opportunity to promote utilization of a learning collaborative model, as has been piloted with Implement-HF,³⁹ for transplant centers to discuss best practices in social needs assessment and intervention to improve transplant access in diverse communities. Development of such an enhanced registry initiative will require changing the physical opportunity involving data reporting, data collection, mixed-methods analysis, and new avenues for public reporting.

Table 2.

COM-B Changes to Improve Transplant Access to Diverse Racial and Ethnic Populations

COM-B Components	Increased Transparency regarding Transplant Candidacy and Allocation	Improved Awareness Regarding Diverse Patient/Community Needs
Physical capability	Health System/Transplant Center/Clinicians: •Clear criteria for transplant candidacy made publicly available to surrounding communities with clarity on what would qualify as a barrier, and if/how barrier is modifiable. •Required use of validated instruments to assess cumulative risk, acuity, and transparency to patient on how this is used by transplant committee in objective decision-making. •Transparency regarding immigration status, transplant financing, and post-transplant medication coverage with resources for assistance. Transparency regarding post-transplant care, including relocation needs and expenses Governing Bodies: •Required reporting from centers on demographics, including zip code and area deprivation, of individuals referred for advanced therapy evaluation, listed, and allocated organs, with public facing summary data, in context of geographic area and those living with advanced HF or pulmonary disease.	Health system: •Develop skills and resources for the process of evaluating social needs, identifying opportunity for social needs intervention, and leveraging community-based resources to meet social needs that may prove barriers to transplant access. •Creating formal paths to publish institutional level data regarding referral, evaluation, and transplant access across diverse communities and assessed community needs and interventions. •Use of validate shared-decision making frameworks for transplant candidacy discussion and consideration at the patient level (to improve health literacy). Governing Bodies/Regulatory: Develop a data resource repository for social needs assessments for consideration of transplant candidacy and interventions offeredPatients: Openly interface with formal assessment of their needs. Community: Increase avenues for recipient and candidate cross/talk, advocacy programsFunding Bodies: Allocate funding and research for implementation science to improve transplant equity
Psychological capability	Health System/Transplant Center/Clinicians: •Multi-disciplinary selection committee for candidate selection with use of validated, objective psychosocial assessments. •Implementation of validated, objective decision-making process. •Mandatory bias training for selection committee members with standardization and oversight of training and assessment of objective decision-making capacity, i.e. institution of best practice standard in transplant decision making. •Training for holistic review of SDOH Governing Bodies: Mandatory training requirements in bias reduction for centers to maintain certificationProfessional Societies: Medication education offerings in bias reduction in transplant consideration/allocation that would meet requirements.	Transplant Centers and providers: Skillset cultivation in bias recognition and reduction (implicit and explicit).Civic leaders/policymakers: Develop awareness around community needs and transplant barriers and evidence-based interventions to improve policymaking impacting transplant access and coverageCommunity/religious leaders: knowledge regarding transplantation indication and candidacy criteria and leverage advocacy extenders for vulnerable communities (community health workers, patient navigators).
Physical opportunity	Governing Bodies and Transplant Centers: networks and resources to leverage big data, including across multiple regions for transplant access factors. Researchers: •Build validated, non-biased, big data processing models •Webpages/internet/printed resources that are easily accessible to public with criteria for transplant candidacy •Guide for patients with steps on how to be referred or self-refer	Health system: effort, salary supported community engagement liaison and transplant clinician champions tasked with improving access to transplantation across diverse communities Governing Bodies: •Method for collecting, storing, and reporting social needs assessments and intervention data •Formal assessment of needs with validated methods and best practice utilization. •Platform to disseminate findings- research findings, diverse streams of communication to reach providers and patients Professional Societies/Advocacy Organization/Transplant Community: Leveraging networks to increase recipient ambassadors for discussion with possible candidates
Social opportunity	•Current social and political influences may create increased inertia and hesitancy around needed and evidenced-based equity focused interventions •Considerations around public reporting of transplant access for individual centers, may increase transplant volumes for already well-performing centers	•Political climate and culture regarding discussing and addressing well-researched and described disparities in equitable access/outcomes •Expansion of patient centered research to include issues of equity in transplant access •Limiting overcompliance with anti-equity policies that may limit innovation in equitable access
Reflective motivation	•Feasible, can be done •Significant optimism that better transparency will increase transplant referrals, access, and allocation •Social obligation as stewards of a public resource to ensure transparency around allocation •Goal is for every patient with severe HF or lung failure to understand what is required to be a candidate in their hometown or closest center	•Change is feasible and can be scaled to health system and broader community level •Health system level– money, time, staffing (human resources) reward at the health system level may be limiting factors
Automatic motivation	•Regulatory intervention will likely aid reinforcement in addition to transplant centers being held accountable by providers and community advisory boards •Emotion to overcome discomfort with externalization of internal policies, discomfort with transitioning subjective to objective discussions	•Modifiable factors can be addressed at the health system and community level that would improve transplant access •Community-wide sentiment of trust and transplant impress can uplift the entire community to be empowered to equitably share a scarce resource and to optimize care to prevent HF progression/lung disease progression. This may also increase donation practices.
Behavioral Diagnosis	Physical capability: training (e.g. multi-disciplinary team on social needs and resources for intervention)Psychological capability: education, training (e.g. objective assessments of social history), and enablement		Physical capability: training and enablement (e.g. creating model share)Physical opportunity: restriction, environmental restructuring of registries, enablement of relationships between transplant centers and community leaders with shared communication of transplant requisites, goals, and expectations

Figure 2.

COM-B Improving Transplant Access to Diverse Racial and Ethnic Populations. (a) Increased Transparency Regarding transplant Candidacy And Allocation; (b) Improved Awareness regarding Diverse Patient and Community Needs for Transplant Consideration.

Additional considerations for improving psychologic capability include foundational knowledge in equity and bias reduction for the multidisciplinary transplant committee participants and improving knowledge regarding transplantation candidacy and access among civic and community leaders and diverse referring providers.

Behavioral diagnosis

Physical and psychological capability and physical opportunity would be the necessary foci for targeted behavior change to increase awareness regarding diverse patient and community needs for transplant consideration. Physical capability for transplant candidacy cab be targeted to better assess social needs and interventions through training, such as training the multi-disciplinary team on social needs and resources for intervention, and enablement, creating a model share across centers with a regulatory environment that requires accountability for assessments and contraindications. Psychological capability can be addressed through training on objective assessments of social support and on holistic assessments of SDOH. Similarly, physical opportunity to restructure registries for this purpose and enable center to change the way they operate so that community leaders are aware of center policies for transplant consideration and transplant centers are aware of community needs. Training efforts were considered affordable and practice, though more data would be needed to understand effectiveness, and acceptability. Adjusting data reporting and registries will require higher upfront costs but may prove to be a valuable investment for transplant equity.

Existing evidence-based interventions

Evidence-based interventions directly addressing physical and psychological capability and physical opportunity to improve equity in transplant access are limited. Implementation science frameworks, such as the Pragmatic Robust Implementation and Sustainability Model (PRISM) have been applied for racial equity in living donor kidney transplantation⁴⁰, demonstrating applicability of implementation science, but evidence regarding feasibility and efficacy are forthcoming. In addition, outcomes are forthcoming from the System Interventions to Achieve Early and Equitable Transplants (STEPS) Study⁴¹, a study focused on quality and patient needs to improve access to kidney transplants. Another pilot study utilized the behavior change wheel framework to impact decision making processes amongst evaluating committees for transplant candidacy.42, 43 The Seeking Objectivity in Allocation of Advanced HF (SOCIAL-HF) Therapies study demonstrates intervention on a behavioral diagnosis to improve psychological capability and social opportunity to promote fair access in allocation. A pragmatic, randomized, controlled cluster design trial⁴⁴ among 14 U.S.-based transplant centers is now underway. Further implementation science studies are needed to better understand and impact ethical transplant access.

Improving access with patient-centered approaches

Defining the problem in behavioral terms

Successful implementation requires recognition of the problem across all stakeholders. Program leadership must ensure that patients are included from the outset and that providers receive education to mitigate bias. Providers, including clinicians, nurses, psychologists, social workers, and other allied healthcare professionals (HCPs), should engage patients in transparent discussions. HCPs are responsible for conducting individualized assessments tailored to each patient’s context and needs. Finally, patients and providers should collaborate in developing an action plan. Overall, implementation depends on coordinated stakeholder engagement, early patient inclusion, provider preparedness, individualized assessments, and shared planning.

Prioritizing target behavior

Among the candidate behaviors, all were judged to have high potential impact. Individualized comprehensive assessments emerged as the primary priority because they combine high impact with relative ease of change, strong spillover potential, and ease of measurement. Development of an individualized action plan was also prioritized as a closely linked target behavior, given its high impact, relative feasibility, and potentially strong spillover, particularly as a direct extension of assessment findings. Early patient engagement was likewise considered highly impactful, with high spillover, although somewhat more difficult to change and measure. Implementing deliverables was also recognized as highly impactful and capable of generating strong spillover, but it was considered the most difficult behavior to change. Overall, individualized comprehensive assessments and the development of an individualized action plan were prioritized as the most feasible, strategic, and mutually reinforcing starting points for implementation.

Specifying selected target behavior

The two selected target behaviors are closely interconnected and should be understood as sequential, mutually reinforcing components of the same patient-centered process. Individualized comprehensive assessments provide the informational and relational foundation for care, whereas the individualized action plan translates assessment findings into concrete, coordinated strategies.

1. Individualized comprehensive assessments: The first target behavior should be performed by a multidisciplinary team in partnership with the patient and caregiver(s). This requires the development and early use of appropriate tools, ideally beginning at diagnosis, and should occur in person or virtually at every touch point, with involvement of the patient’s support system where appropriate.

2. Development of an individualized plan: The second target behavior should likewise be carried out by the multidisciplinary team in collaboration with the patient and caregiver(s). Built directly on assessment data, it should begin early, be delivered in person or virtually, and be reviewed and updated every six months, with support from relevant organizations and policymakers when needed.

COM-B behaviors to change

The COM-B analysis indicates that implementation of individualized comprehensive assessments and individualized action plans requires change across all six behavioral domains (Table 3, Figure 3). Because these two target behaviors are closely interconnected, the behavioral requirements supporting them substantially overlap. Comprehensive assessments identify needs, barriers, and available resources, whereas the action plan operationalizes these findings into tailored interventions. Together, they constitute a single implementation pathway, with particularly important leverage points in psychological capability and reflective motivation.

Table 3.

COM-B Changes to Improve Access with Patient-Centered Approaches

COM-B component	Individualized Comprehensive Assessment and Plan
Physical capability	Patients: adequate digital abilities to use internet-based tools and platforms
Psychological capability	Patients and HCPs: stronger communication skillsHCPs: •Trust-building with patients •Bias recognition and mitigation •Avoidance of medical jargon
Physical opportunity	Services/programs: •Accessibility of devices and virtual spaces •Availability of multilingual resources •Availability of standardized assessments
Social opportunity	Services/programs and teams: inclusive evaluation and care processes for minoritized and other vulnerable groups at risk of discrimination
Reflective motivation	Patients: greater sense of agency in care and decision-makingClinicians/HCPs: stewardship aligned with patient-centered implementation
Automatic motivation	Services/programs and teams: •Reinforcement through research-informed practice •Feedback from other centers
Behavioral Diagnosis	Psychological capability: education, training, and enablement on use of individualized comprehensive assessment plans may include workshops, audit and feedback to improve collection of data.Reflective motivation: Education may be used to understand how the strategy results in better outcomes with comprehensive plans.

HCPs indicates Healthcare Professionals.

Figure 3.

COM-B Improving Access with Patient-centered Approaches. Individualized Comprehensive Assessment and Plan.

At the level of physical capability, some patients may require sufficient digital abilities to use internet-based tools, virtual platforms, or online resources. Psychological capability is especially important. Patients and HCPs need strong communication skills, while HCPs must also recognize and actively mitigate bias, avoid medical jargon, and foster trusting relationships with patients. These elements are essential both for generating meaningful assessment data and for developing action plans that are understandable, acceptable, and feasible.

Physical opportunity must also be strengthened. Patients need access to appropriate devices and suitable virtual spaces, while services must ensure the availability of multilingual resources and standardized assessment tools. Social opportunity is equally relevant, particularly the need to ensure that evaluation and care processes are inclusive of minorities and other vulnerable individuals who may be at risk of exclusion or discrimination. Without such inclusive structures, both assessment and planning may fail to identify or address inequities.

Reflective motivation represents another key domain. Patients may feel that they have limited power in their own care and may perceive self-advocacy as an excessive burden. At the same time, clinicians’ stewardship role may either facilitate or hinder implementation, depending on how patient-centered it is enacted. Automatic motivation may be reinforced through research-informed practice, feedback from other centers, and exposure to examples of good practice that normalize these behaviors.

Overall, the behavioral diagnosis suggests that interventions should primarily target psychological capability and reflective motivation. In practice, this points to education, training, and enablement to strengthen capability, alongside education, persuasion, incentivization, and supportive policy or organizational strategies to enhance motivation and sustain implementation.

Behavioral diagnosis

Individualized comprehensive assessments and planning were selected as target behaviors because they strongly meet the APEASE criteria. Prioritized diagnoses including addressing psychological capability and reflective motivation. Education, training, and enablement on use of individualized comprehensive assessment plans may include audit and feedback to improve collection of data. Education may be used to understand how the strategy results in better outcomes with comprehensive plans. They are affordable and practical when supported by standardized tools that can be used across in-person and virtual settings. They are also likely to be effective because they enable early identification of needs, barriers, vulnerabilities, and available supports, thereby facilitating more tailored care. Inherently, this supports shared decision-making. In addition, they are acceptable because they align with patient-centered practice and support meaningful involvement of patients and caregivers. They are also safe, as they reduce the risk of missed needs, poor communication, and biased assumptions, while promoting equity through the systematic identification of language barriers, discrimination risks, and other vulnerabilities.

Existing evidence-based interventions that meet behavioral diagnosis needs

Existing evidence supports multicomponent interventions combining education, training, and enablement, delivered through workshops, webinars, case-based sessions, videos, audit-and-feedback, facilitation, and ongoing mentorship.45, 46, 47, 48 In transplant settings, the strongest evidence comes from programs such as Reducing Disparities in Access to kidNey Transplantation Community Study (RaDIANT), Allocation System for changes in Equity in Kidney Transplantation (ASCENT), the Hispanic Kidney Transplant Program(HKTP), and SOCIAL HF, which used provider-facing strategies—including staff education, training, standardized assessment tools, audit-and-feedback, and leadership engagement—and patient-/family-facing strategies—including peer mentoring, culturally and linguistically tailored materials, outreach, navigation, and family-centered education to improve referral, waitlisting, and equitable processes.42, 45, 47, 49 In advanced HF settings, SOCIAL HF showed that brief interactive team sessions plus leader training can improve group dynamics and may reduce mistreatment in allocation practices.⁴² Taken together, the available evidence suggests that implementation strategies should favor longitudinal rather than one-time delivery, ideally through hybrid in-person/virtual formats and with support from local champions or facilitators. Interventions should also be theory-informed, tailored to stakeholder and contextual needs, and intentionally designed to address structural barriers, including language, workflow constraints, access limitations, and inequities affecting vulnerable populations.

Developing transplant programs in under-resourced countries

Defining the problem in behavioral terms

Equitable access to heart and lung transplantation in under-resourced countries is limited less by a single clinical decision than by the absence of repeated, coordinated system-building behaviors. The actors include ministries of health, transplant authorities or quasi-governmental bodies, national cardiovascular and respiratory societies, hospital leaders, intensive care and surgical teams, transplant coordinators, public-health organizations, and community stakeholders. These actors must routinely identify capable centers, create legal and ethical donation/allocation governance, secure financing, train multidisciplinary teams, protect access to immunosuppression and post-transplant surveillance, and report data. The World Health Organization has called for donation, transplantation, and transplant follow-up to be integrated within health systems with oversight and ethical access.⁵⁰ Global activity data show continuing growth in transplantation but persistent geographic disparities, underscoring the need for country-level program development rather than ad hoc referral abroad.⁵¹ Ethical guidance further emphasizes donor protection, transparent allocation, and national self-sufficiency.52, 53

Prioritizing target behavior

Several candidate behaviors were identified: identifying centers with transplant-relevant expertise; identifying barriers to deceased organ donation; increasing government involvement in transplant infrastructure and wait-list management; creating national information campaigns; establishing data collection and registry capacity; reducing barriers to post-transplant medications and surveillance; and achieving adequate transplant capacity. Two behaviors were prioritized. First, governments and transplant leaders should create a national or regional heart and lung transplant infrastructure and workforce plan. This behavior was judged high impact because governance affects referral, donation, wait-listing, procurement, surgery, intensive care, immunosuppression, and long-term follow-up, but it is difficult to change. Second, countries should identify and formally designate experienced centers as pilot transplant hubs or consortium nodes. This behavior is more immediately feasible and creates a visible starting point for training, referral standardization, quality review, and regional mentorship. Registry development, public awareness, and post-transplant.

Specifying selected target behavior

1. Develop a national or regional heart and lung transplant infrastructure and workforce plan: The ministry of health, national transplant authority, or designated quasi-governmental organization would need to convene a multidisciplinary steering group and produce a written heart and lung transplant readiness plan with a budget, accountable leadership, and implementation milestones within 12 months. The plan should define legal authority, ethical oversight, donor identification, organ procurement and allocation, financing, referral pathways, laboratory and diagnostic capacity, operating-room and intensive-care requirements, immunosuppression access, workforce training, data reporting, and post-transplant follow-up.

2. Identify and designate transplant-capable centers as pilot hubs or consortium nodes: National clinical societies and hospital leaders would need to map existing capacity and designate at least one pilot center or regional hub within 6–12 months. Minimum criteria should include advanced HF and/or advanced lung disease referral pathways, cardiothoracic surgery, anesthesia, perfusion, intensive care, transplant coordination, pharmacy, infectious diseases, immunology, pathology, psychosocial assessment, rehabilitation, and data-reporting capacity. Designated hubs should operate within a transparent consortium that supports national referral, mentorship, quality review, and regional cooperation.

COM-B behaviors to change

1. Develop a national or regional heart and lung transplant infrastructure and workforce plan: This requires psychological capability for policymakers and hospital leaders to understand transplantation as a continuum of prevention, referral, donation, allocation, surgery, critical care, rehabilitation, and lifelong follow-up rather than a single operation (Table 4, Figure 4a).⁵⁴ Practically this requires knowledge of legislation, death determination, donor management, candidate evaluation, organ allocation, infection prevention, pathology, immunology, pharmacy, cost protection, and registry reporting. Education, training, technical assistance, and structured readiness tools are therefore essential. Physical and social opportunity require legal authorization, an accountable national body, financing, authorized centers, procurement logistics, quality and safety standards, and reliable access to immunosuppression and surveillance testing. These components are consistent with calls for government accountability, whole-system national program evaluation, and lessons from successful national models.55, 56, 57 Reflective motivation can be strengthened by framing transplant development as an equity, noncommunicable disease, and health-system-resilience priority, while transparent governance and safeguards against trafficking increase public trust.52, 53

Table 4.

COM-B Changes to Develop Transplant Programs in Under-Resourced Countries

COM-B Components	Develop a national or regional heart and lung transplant infrastructure and workforce plan	Identify and designate transplant-capable centers as pilot hubs or consortium nodes
Physical capability	Workforce trained to competently perform death determination, donor management, candidate evaluation, organ procurement and allocation, infection prevention, pathology, immunology, pharmacy, and registry reporting, delivered through structured readiness tools and train-the-trainer education	Clinicians and administrators able to assess center readiness, identify gaps, and implement minimum-standard protocols for referral, evaluation, donor identification and management, surgery, and follow-up, supported by the multidisciplinary expertise described in ISHLT heart and lung candidate guidelines
Psychological capability	Policymakers and hospital leaders understand transplantation as a continuum of prevention, referral, donation, allocation, surgery, critical care, rehabilitation, and lifelong follow-up rather than a single operation, with working knowledge of transplant law, ethics, financing, and registry reporting	Recognition that absence of current transplant activity does not equal absence of potential capacity, and the ability to map existing capacity stepwise against defined minimum criteria
Physical opportunity	Legal authorization, an accountable national or regional authority, sustainable financing, authorized centers, procurement logistics, laboratory/ICU/operating-room capacity, quality and safety standards, and reliable access to immunosuppression and surveillance testing	Existing cardiac, advanced lung, and intensive-care infrastructure; explicit referral networks; protected coordinator time; donor identification and management protocols; and access to essential diagnostics and therapeutics
Social opportunity	Cross-stakeholder coordination among ministries of health, transplant authorities, national societies, and hospital leaders, with government accountability and public trust reinforced by transparent governance and safeguards against trafficking	Consortium structures and channels for international and regional collaboration and mentorship, with shared recognition that concentrating expertise prevents unsafe diffusion across unprepared hospitals
Reflective motivation	Framing transplant program development as an equity, noncommunicable-disease, national self-sufficiency, and health-system-resilience priority	Hub designation linked to professional development, accreditation, quality improvement, and improved survival, balanced against awareness that premature diffusion without minimum standards undermines safety and trust
Automatic motivation	Accountable leadership, a dedicated budget line, defined implementation milestones, and a reporting cadence that reinforce sustained system-building behavior	Reinforcement through accreditation status, audit-feedback, quality reporting, and visible milestones
Behavioral Diagnosis	Psychological capability and physical and social opportunity: education, training, enablement, environmental restructuring	Physical and psychological capability and physical and social opportunity: education, enablement, environmental restructuring

Figure 4.

Developing Transplant Programs in Under-Resourced Countries. (a) Develop a national or regional heart and lung transplant infrastructure and workforce plan. (b) Identify and designate transplant-capable centers as pilot hubs or consortium nodes.

2. Identify and designate transplant-capable centers as pilot hubs or consortium nodes: Physical capability centers on the ability of clinicians and administrators to assess readiness, identify gaps, and implement minimum standards (Table 4, Figure 4b). Capability mapping should not equate absence of current transplant activity with absence of potential capability. Countries with cardiac surgery, advanced HF, pulmonary hypertension or advanced lung disease services, intensive care, and emerging donation systems may develop stepwise transplant capacity through hub designation and external mentorship. ISHLT heart and lung candidate guidelines illustrate the multidisciplinary expertise required for safe evaluation, listing, psychosocial assessment, risk modification, and longitudinal care.58, 59 Physical and social opportunity require explicit referral networks, protected coordinator time, protocols for donor identification and management, access to essential diagnostics and therapeutics, and channels for international or regional collaboration. Motivation is enhanced when hub designation is linked to professional development, accreditation, quality improvement, and improved patient survival; however, premature diffusion without defining clear standard of care metrics could undermine safety and trust.

Behavioral diagnosis

Recommendations to develop a transplant infrastructure and identify transplant capable centers as hubs need intervention functions of education, training, enablement, and environmental restructuring which address physical and psychological capability and physical and social opportunity. Policy categories include guidelines, regulation, service provision, fiscal measures, and communication.

The first target behavior meets criteria because it is likely to be highly effective and equity-enhancing: without national infrastructure, access remains dependent on wealth, geography, medical tourism, or informal external referral. Although initially costly and politically difficult, a phased readiness plan is practical if it begins with existing assets, defines a limited pilot scope, protects essential post-transplant medications, and incorporates regional cooperation. It is acceptable and safe when linked to transparent allocation, donor protection, ethical oversight, and outcome monitoring.

The second target behavior is more affordable and practical because mapping and designation can begin before a full national program exists. It is likely acceptable to clinicians and policymakers because it concentrates expertise, creates visible milestones, and avoids unsafe diffusion of complex procedures across unprepared hospitals. Equity risks must be mitigated by requiring national referral criteria, public reporting, and mechanisms for patients from underserved regions to reach designated hubs.

Existing evidence-based interventions

Existing evidence supports program-level strategies rather than isolated center efforts. WHO guidance and the Declaration of Istanbul support legal oversight, equitable allocation, donor protection, transplant follow-up, and self-sufficiency.50, 52, 53 The Global Observatory on Donation and Transplantation provides benchmarking and demonstrates the importance of minimum data reporting.⁵¹ Conceptual frameworks and the Spanish model support national authorities, designated centers, donation coordination, registries, audit-feedback, and sustained political leadership.56, 57 The ISHLT Registry demonstrates the value of standardized international outcome monitoring for thoracic transplantation.⁶⁰ Country gap analyses illustrate how such frameworks can be translated into concrete recommendations for underperforming or developing programs.⁶¹

Practical delivery for under-resourced countries should use a staged package: baseline national gap assessment; designation of governmental and clinical champions; train-the-trainer education for coordinators, intensivists, surgeons, cardiologists, pulmonologists, nurses, pharmacists, and data managers; virtual mentorship and site visits from established centers; standardized operating procedures for referral, evaluation, donor identification, allocation, surgery, and follow-up; and audit-feedback using a minimum registry. Early measures should include completion of a readiness plan, number of designated hubs, workforce trained, donor referrals, waitlisted candidates, transplant volume, one-year survival, medication access, and registry completeness.

Discussion

This ISHLT consortium identified four foci for improving global access to heart and lung transplantation and prioritized targeted behavior to achieve these objectives. First, to improve quality of transplant data for access and outcomes, priorities included: 1) improving collection of SDOH, race, and ethnicity data, and 2) collection of data on patients referred but not listed. Second, to improve transplant access to diverse racial and ethnic populations, priorities were: 1) increasing transparency regarding candidacy and allocation, and 2) improved awareness regarding diverse patient and community needs for transplant consideration. Third, to improve access with patient-centered approaches, an individualized comprehensive assessment and plan was prioritized. Lastly, to develop transplant programs in under-resourced countries, priorities included: 1) developing a national or regional heart and transplant infrastructure and workforce plan, and 2) identifying and designating transplant capable centers as pilot hubs or consortium nodes.

Major system change is possible by starting with small changes in behavior. Using COM-B/BCW we have identified the most feasible starting steps to lead to equitable access to global heart and lung transplantation. Many would be facilitated by governing body support to regulate changes in data capture as well changing prerequisites for transplant programs, but some can be performed at local levels initially. Programs can institute many of the trainings associated with improving physical and psychological capability. Reflective motivation can be addressed via persuasion with audit and feedback since examining how one’s efforts contributes to a potentially favorable outcome creates a positive feedback loop.⁶² Physical opportunity can be addressed by restructuring existing electronic medical records to retain the data on SDOH and related issues that help improve care, particularly as many electronic medical systems evolve and as views on the importance of this data improve. Social opportunity can be addressed by enabling relationships with community members; a few dedicated leaders can initiate these relationships that have potential to change the way a transplant program is built and sustained.

This consortium document also serves as directions for future research strategies. Several clinical studies and quality initiatives may be based upon the prioritization of this consortium. Existing international and national registries may be expanded to collect needed data as contracts are redrawn and designed to meet contemporary needs for evidence to support access to transplantation. Granularity will be of prime importance to enhance generalizability across diverse populations. Cost justifications can be considered in comparative effectiveness studies that address these priorities.

Limitations

We acknowledge that this consortium document does not represent every country and discipline experiencing disparate access to heart and lung transplantation. This consortium was primarily composed of clinicians, medical and surgical, and notably misses expertise from other disciplines. However, the initial ISHLT workshop and the subsequent one included representation from countries and populations that experience some of the highest levels of advanced heart and lung disease. Several authors currently or previously provided clinical care or conducted clinical research in multiple countries and have offered their lived experiences. We do not describe all strategies selected by consortium, rather we focused on the more prioritized strategies that also meet APEASE criteria. To our knowledge, this is the first consortium to describe strategies to feasibly improve heart and lung transplant access globally using the COM-B/BCW framework.

Conclusions

Global inequities in heart and lung transplantation are expansive but addressable. Among an international consortium of clinicians, healthcare leaders, and scientists in advanced heart and lung diseases, we described strategies to improve access to heart and lung transplantation according to established implementation science framework, COM-B/ BCW. This framework addressed behavior change at the fundamental level, which is applicable for individual and system-level changes. Behaviors were outlined to improve quality of transplant data for access and outcomes, improve transplant access to diverse racial and ethnic populations, improve access with patient-centered approaches, and to develop transplant programs in under-resourced countries. Implementation of strategies in quality improvement and research studies has great potential to improve equity in access to care.

Sources of Funding

Dr. Breathett receives grant funding from the National Heart, Lung, and Blood Institute (NHLBI) R01HL159216, R01HL16074, Indiana Clinical and Translational Sciences Institute, and Indiana University.

Information for Authors

Some authors used artificial intelligence for editing and English language refinement. Contents are original.

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Khadijah Breathett, MD, MS reports a relationship with National Institutes of Health that includes: funding grants. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.