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Wahid N, Lee J, Rosenblatt R, Kaplan A, Tipirneni R, Fortune BE, Safford M, Brown RS. Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality. Liver Transpl 2024; 30:20-29. [PMID: 37486623 DOI: 10.1097/lvt.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
It is unclear what impact Affordable Care Act (ACA) Medicaid expansion has had on the liver transplantation (LT) waitlist. We aimed to assess associations between ACA Medicaid expansion and LT waitlist outcomes. The United Network for Organ Sharing Standard Transplant Analysis and Research (UNOS STAR) database was queried for patients listed for LT between January 1, 2009, and December 31, 2018. Our primary outcome was waitlist mortality and our secondary outcomes included Medicaid use on the LT waitlist and transplant rate. States were divided into groups based on their expansion status and the study period was divided into 2 time intervals-pre-expansion and post-expansion. Difference-in-difference (DiD) models were created to assess the impacts of expansion on each of the outcomes and for racial/ethnic and sex groups. In total, 56,414 patients from expansion states and 32,447 patients from nonexpansion states were included. Three-year waitlist mortality decreased at a similar rate in both cohorts [DiD estimate: 0.1, (95% CI, -1.1, -1.4), p = 0.838], but Medicaid use increased [DiD estimate: +7.7, (95% CI, 6.7, 8.7), p < 0.001] to a greater degree in expansion states after expansion than nonexpansion states. Between the 2 time intervals, Medicaid use on the LT waitlist increased from 19.4% to 26.1% in expansion states but decreased from 13.4% to 12.1% in nonexpansion states. In patients on Medicaid, there was a slight increase in the 3-year transplant rate associated with Medicaid expansion [DiD estimate +5.0, (95% CI, 1.8, 8.3), p = 0.002], which may in part be explained by differences in patient characteristics. Medicaid expansion was associated with increased Medicaid use on the LT waitlist without worsening overall waitlist mortality or transplant rate, suggesting that lenient and widespread public health insurance may increase access to the LT waitlist without adversely affecting outcomes.
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Affiliation(s)
- Nabeel Wahid
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Jihui Lee
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyson Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Renuka Tipirneni
- Department of Internal Medicine, Division of General Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Brett E Fortune
- Department of Medicine, Division of Hepatology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Monika Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
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2
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Wahid NA, Lee J, Kaplan A, Fortune BE, Safford MM, Brown RS, Rosenblatt R. Medicaid Expansion Association With End-Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage. Liver Transpl 2021; 27:1723-1732. [PMID: 34118120 DOI: 10.1002/lt.26209] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
The Affordable Care Act expanded Medicaid around the same time that direct-acting antivirals became widely available for the treatment of hepatitis C virus (HCV). However, there is significant variation in Medicaid HCV treatment eligibility criteria between states. We explored the combined effects of Medicaid expansion and leniency of HCV coverage under Medicaid on liver outcomes. We assessed state-level end-stage liver disease (ESLD) mortality rates, listings for liver transplantation (LT), and listing-to-death ratios (LDRs) for adults aged 25 to 64 years using data from United Network for Organ Sharing and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. States were divided into 4 nonoverlapping groups based on expansion status on January 1, 2014 (expansion versus nonexpansion) and leniency of Medicaid HCV coverage (lenient versus restrictive coverage). Joinpoint regression analysis evaluated the significant changes in slope over time (joinpoints) during the pre-expansion (2009-2013) and postexpansion (2014-2018) time periods. We found significant changes in the annual percent change for population-adjusted ESLD deaths between 2014 and 2015 in all cohorts except for the nonexpansion/restrictive cohort, in which deaths increased at the same annual percent change from 2009 to 2018 (annual percent change of +2.5%; 95% confidence interval [CI], 1.8-3.3]). In the expansion/lenient coverage cohort, deaths increased at an annual percent change of +2.6% (95% CI, 1.8-3.5) until 2014 and then tended to decrease at an annual percent change of -0.4% (95% CI, -1.5 to 0.8). LT listings tended to decrease over time for all cohorts. For LDRs, only the expansion/lenient and expansion/restrictive cohorts had statistically significant joinpoints. Improvements in ESLD mortality and LDRs were associated with both Medicaid expansion and leniency of HCV coverage under Medicaid. These findings suggest the importance of implementing more lenient and widespread public health insurance to improve liver disease outcomes, including mortality.
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Affiliation(s)
- Nabeel A Wahid
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY
| | - Jihui Lee
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Alyson Kaplan
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Brett E Fortune
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Robert S Brown
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Russell Rosenblatt
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
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Emamaullee JA, Aljehani M, Hogen RVT, Zhou K, Lee JSH, Sher LS, Genyk YS. Potential association between public medical insurance, waitlist mortality, and utilization of living donor liver transplantation: An analysis of the Scientific Registry of Transplant Recipients. Clin Transplant 2021; 35:e14418. [PMID: 34236113 DOI: 10.1111/ctr.14418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/28/2021] [Accepted: 07/04/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) and subsequent Medicaid expansion has increased utilization of public health insurance. Living donor liver transplantation (LDLT) increases access to transplant and is associated with improved survival but consistently represents < 5% of LT in the United States. STUDY DESIGN National registry data were analyzed to evaluate the impact of insurance payor on waitlist mortality and LDLT rates at LDLT centers since implementation of the ACA. RESULTS Public insurance [Medicare RR 1.18 (1.13-1.22) P < .001, Medicaid RR 1.22 (1.18-1.27) P < .001], Latino ethnicity (P < .001), and lower education level (P = .02) were associated with increased waitlist mortality at LDLT centers. LDLT recipients were more likely to have private insurance (70.4% vs. 59.4% DDLT, P < .001), be Caucasian (92.1% vs. 83% DDLT, P < .001), and have post-secondary education (66.8% vs. 54.1% DDLT, P < .001). Despite 78% of LDLT centers being located in states with Medicaid expansion, there was no change in LDLT utilization among recipients with Medicaid (P = .196) or Medicare (P = .273). CONCLUSION Despite Medicaid expansion, registry data suggests that patients with public medical insurance may experience higher waitlist mortality and underutilize LDLT at centers offering LDLT. It is possible that Medicaid expansion has not increased access to LDLT.
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Affiliation(s)
- Juliet A Emamaullee
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, California, USA
| | - Mayada Aljehani
- Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California, Los Angeles, California, USA
| | - Rachel V T Hogen
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, California, USA
| | - Kali Zhou
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jerry S H Lee
- Lawrence J. Ellison Institute for Transformative Medicine, University of Southern California, Los Angeles, California, USA
| | - Linda S Sher
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, California, USA
| | - Yuri S Genyk
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, California, USA
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Barbetta A, Aljehani M, Kim M, Tien C, Ahearn A, Schilperoort H, Sher L, Emamaullee J. Meta-analysis and meta-regression of outcomes for adult living donor liver transplantation versus deceased donor liver transplantation. Am J Transplant 2021; 21:2399-2412. [PMID: 33300241 PMCID: PMC9048132 DOI: 10.1111/ajt.16440] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 01/25/2023]
Abstract
Prior single center or registry studies have shown that living donor liver transplantation (LDLT) decreases waitlist mortality and offers superior patient survival over deceased donor liver transplantation (DDLT). The aim of this study was to compare outcomes for adult LDLT and DDLT via systematic review. A meta-analysis was conducted to examine patient survival and graft survival, MELD, waiting time, technical complications, and postoperative infections. Out of 8600 abstracts, 19 international studies comparing adult LDLT and DDLT published between 1/2005 and 12/2017 were included. U.S. outcomes were analyzed using registry data. Overall, 4571 LDLT and 66,826 DDLT patients were examined. LDLT was associated with lower mortality at 1, 3, and 5 years posttransplant (5-year HR 0.87 [95% CI 0.81-0.93], p < .0001), similar graft survival, lower MELD at transplant (p < .04), shorter waiting time (p < .0001), and lower risk of rejection (p = .02), with a higher risk of biliary complications (OR 2.14, p < .0001). No differences were observed in rates of hepatic artery thrombosis. In meta-regression analysis, MELD difference was significantly associated with posttransplant survival (R2 0.56, p = .02). In conclusion, LDLT is associated with improved patient survival, less waiting time, and lower MELD at LT, despite posing a higher risk of biliary complications that did not affect survival posttransplant.
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Affiliation(s)
- Arianna Barbetta
- Department of Surgery, University of Southern California, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Mayada Aljehani
- Lawrence J Ellison Institute for Transformative Medicine, University of Southern California, Los Angeles, CA
| | - Michelle Kim
- Department of Surgery, University of Southern California, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Christine Tien
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Aaron Ahearn
- Department of Surgery, University of Southern California, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Linda Sher
- Department of Surgery, University of Southern California, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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Wahid NA, Rosenblatt R, Brown RS. A Review of the Current State of Liver Transplantation Disparities. Liver Transpl 2021; 27:434-443. [PMID: 33615698 DOI: 10.1002/lt.25964] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/16/2020] [Accepted: 12/04/2020] [Indexed: 12/19/2022]
Abstract
Equity in access is one of the core goals of the Organ Procurement and Transplant Network (OPTN). However, disparities in liver transplantation have been described since the passage of the National Organ Transplant Act, which established OPTN in the 1980s. During the past few decades, several efforts have been made by the United Network for Organ Sharing (UNOS) to address disparities in liver transplantation with notable improvements in many areas. Nonetheless, disparities have persisted across insurance type, sex, race/ethnicity, geographic area, and age. African Americans have lower rates of referral to transplant centers, females have lower rates of transplantation from the liver waiting list than males, and public insurance is associated with worse posttransplant outcomes than private insurance. In addition, pediatric candidates and older adults have a disadvantage on the liver transplant waiting list, and there are widespread regional disparities in transplantation. Given the large degree of inequity in liver transplantation, there is a tremendous need for studies to propose and model policy changes that may make the liver transplant system more just and equitable.
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Affiliation(s)
- Nabeel A Wahid
- Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
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Gutin L, Yao F, Dodge JL, Grab J, Mehta N. Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance. JAMA Netw Open 2019; 2:e1910326. [PMID: 31469395 PMCID: PMC6724163 DOI: 10.1001/jamanetworkopen.2019.10326] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. OBJECTIVE To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. DESIGN, SETTING, AND PARTICIPANTS This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. MAIN OUTCOMES AND MEASURES The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. RESULTS Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). CONCLUSIONS AND RELEVANCE In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.
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Affiliation(s)
- Liat Gutin
- Department of Medicine, University of California, San Francisco
| | - Francis Yao
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Joshua Grab
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
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Akateh C, Tumin D, Beal EW, Mumtaz K, Tobias JD, Hayes D, Black SM. Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes. Dig Dis Sci 2018; 63:1463-1472. [PMID: 29574563 PMCID: PMC6425937 DOI: 10.1007/s10620-018-5031-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/15/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear. AIMS To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation. METHODS We queried the United Network for Organ Sharing for patients between ages 18-64 years undergoing liver transplantation in 2002-2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival. RESULTS Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure. CONCLUSION Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.
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Affiliation(s)
- Clifford Akateh
- Division of General and Gastrointestinal Surgery, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA,Division of Transplantation, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA,Ohio State University Wexner Medical Center - Faculty Tower, 395 W 12th Ave, Room 654, Columbus, OH 43210-1267, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Eliza W. Beal
- Division of General and Gastrointestinal Surgery, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA,Division of Transplantation, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Anesthesiology and Pain Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43205, USA
| | - Don Hayes
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA,Section of Pulmonary Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH 43205, USA,Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Sylvester M. Black
- Division of Transplantation, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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8
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Tumin D, Li SS, Nandi D, Gajarski RJ, McKee C, Tobias JD, Hayes D. Health Insurance Coverage among Young Adult Survivors of Pediatric Heart Transplantation. J Pediatr 2017; 188:82-86. [PMID: 28690004 DOI: 10.1016/j.jpeds.2017.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/04/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe the change in health insurance after heart transplantation among adolescents, and characterize the implications of this change for long-term transplant outcomes. STUDY DESIGN Patients age 15-18 years receiving first-time heart transplantation between 1999 and 2011 were identified in the United Network for Organ Sharing registry and included in the analysis if they survived at least 5 years. The primary exposure was change or continuity of health insurance coverage between the time of transplant and the 5-year follow-up. Cox proportional hazards models were used to determine the association between insurance status change and long-term (>5 years) patient and graft survival. RESULTS The analysis included 366 patients (age 16 ± 1 years at transplant), of whom 205 (56%) had continuous private insurance; 96 (26%) had continuous public insurance; and 65 (18%) had a change in insurance status. In stepwise multivariable Cox regression, change in insurance status was associated with greater mortality hazard, compared with continuous private insurance (hazard ratio = 1.9; 95% CI: 1.1, 3.2; P = .016), whereas long-term patient and graft survival did not differ between patients with continuous public and continuous private insurance. CONCLUSIONS Continuity of insurance coverage is associated with improved long-term clinical outcomes among adolescent heart transplant recipients who survive into adulthood.
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Affiliation(s)
- Dmitry Tumin
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH.
| | - Susan S Li
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Deipanjan Nandi
- Division of Cardiology, Nationwide Children's Hospital, Columbus, OH
| | - Robert J Gajarski
- Division of Cardiology, Nationwide Children's Hospital, Columbus, OH
| | - Christopher McKee
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH; Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH
| | - Don Hayes
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH
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Tumin D, Beal EW, Mumtaz K, Hayes D, Tobias JD, Pawlik TM, Washburn WK, Black SM. Medicaid Participation among Liver Transplant Candidates after the Affordable Care Act Medicaid Expansion. J Am Coll Surg 2017; 225:173-180.e2. [DOI: 10.1016/j.jamcollsurg.2017.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/12/2017] [Accepted: 05/09/2017] [Indexed: 12/11/2022]
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10
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Tumin D, Foraker RE, Smith S, Tobias JD, Hayes D. Health Insurance Trajectories and Long-Term Survival After Heart Transplantation. Circ Cardiovasc Qual Outcomes 2016; 9:576-84. [PMID: 27625403 DOI: 10.1161/circoutcomes.116.003067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/08/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Health insurance status at heart transplantation influences recipient survival, but implications of change in insurance for long-term outcomes are unclear. METHODS AND RESULTS Adults aged 18 to 64 receiving first-time orthotopic heart transplants between July 2006 and December 2013 were identified in the United Network for Organ Sharing registry. Patients surviving >1 year were categorized according to trajectory of insurance status (private compared with public) at wait listing, transplantation, and 1-year follow-up. The most common insurance trajectories were continuous private coverage (44%), continuous public coverage (27%), and transition from private to public coverage (11%). Among patients who survived to 1 year (n=9088), continuous public insurance (hazard ratio =1.36; 95% confidence interval 1.19, 1.56; P<0.001) and transition from private to public insurance (hazard ratio =1.25; 95% confidence interval 1.04, 1.50; P=0.017) were associated with increased mortality hazard relative to continuous private insurance. Supplementary analyses of 11 247 patients included all durations of post-transplant survival and examined post-transplant private-to-public and public-to-private transitions as time-varying covariates. In these analyses, transition from private to public insurance was associated with increased mortality hazard (hazard ratio =1.25; 95% confidence interval 1.07, 1.47; P=0.005), whereas transition from public to private insurance was associated with lower mortality hazard (hazard ratio =0.78; 95% confidence interval 0.62, 0.97; P=0.024). CONCLUSIONS Transition from private to public insurance after heart transplantation is associated with worse long-term outcomes, compounding disparities in post-transplant survival attributed to insurance status at transplantation. By contrast, post-transplant gain of private insurance among patients receiving publicly funded heart transplants was associated with improved outcomes.
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Affiliation(s)
- Dmitry Tumin
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH.
| | - Randi E Foraker
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
| | - Sakima Smith
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
| | - Don Hayes
- From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH
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Increased Mortality in Adult Cystic Fibrosis Patients with Medicaid Insurance Awaiting Lung Transplantation. Lung 2016; 194:799-806. [DOI: 10.1007/s00408-016-9927-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 08/02/2016] [Indexed: 01/20/2023]
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Schlansky B, Shachar C. Implications of expanded medicaid eligibility for patient outcomes after liver transplantation: Caveat emptor. Liver Transpl 2016; 22:1062-4. [PMID: 27265528 DOI: 10.1002/lt.24491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/01/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Barry Schlansky
- Department of Medicine, Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, OR
| | - Carmel Shachar
- Center for Health Law and Policy Innovation, Harvard Law School, Boston, MA
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