*Purpose: One of the motivations for the recent changes to the heart allocation policy was to reduce geographic disparities. We investigated whether heart transplant (HT) rates differed substantially between donation service areas (DSAs) prior to the policy change.

*Methods: Using SRTR data, we estimated HT rates per active-person year using multilevel Poisson regression and empirical Bayes Methods, adjusting only for factors that directly influenced the ranking order (status, blood type, waiting time). We included all patients ≥ 18 years old. We excluded candidates who were listed for simultaneous transplants (i.e. heart/kidney). We defined heart transplant rates per DSA and per heart status as the number of transplants performed for candidates in that status category divided by the number of active person-years spent waiting in that status category.

*Results: We identified 14,128 candidates who were active on the heart transplant waitlist between 1/1/2015 and 12/31/2017. The median incidence rate ratio (MIRR) was 1.72, meaning that similar candidates across different DSAs had a median 1.72-fold difference in HT rate. The HT rate was 13% lower for each 6 month increase in waiting time. Relative to Status 2 patients, the HT rate for status 1B and 1A candidates was 6.16-fold and 46.65-fold greater, respectively.

*Conclusions: Prior to the heart policy change, status had by far strongest impact on HT rate. However, DSA still played a significant role with similar candidates having a 72% greater HT rate based solely on where they live. The new allocation policy introduced more status categories and reduced the priority of the local DSA, so future studies will be required to assess if these changes reduce the role of geography on heart transplant rates.

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