Liver Transpl. 2020 Nov 13. doi: 10.1002/lt.25936. Online ahead of print.
BACKGROUND: While socioeconomic disparities persist both pre- and post-transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States.
METHODS: All adults (≥18 years) listed for LT between 2002-2018 in the United Network for Organ Sharing (UNOS) database were included. The primary outcome was waitlist removal due to death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal-Wallis and chi-squared tests, respectively. Fine and Gray competing-risks regression was used to estimate sub-distribution hazard ratios for risk factors associated with delisting.
RESULTS: Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare and 15.9% by Medicaid. The one-year cumulative incidence of delisting was 9.0% (95% CI: [8.3%-9.8%]) for patients with private insurance, 10.7% [9.9%-11.6%] for Medicare and 10.7% [9.8%-11.6%] for Medicaid. In multivariable competing-risks analysis, Medicare (HR 1.20 [1.17-1.24], p<0.001) and Medicaid (HR 1.20 [1.16-1.24], p<0.001) were independently associated with an increased hazard of death or deterioration compared to private insurance. Additional predictors of delisting included Black race (HR 1.06 [1.02-1.11], p=0.01) and Hispanic ethnicity (HR 1.05 [1.02-1.09], p=0.01), while college education (HR 0.89 [0.84-0.94], p<0.001) and employment (HR 0.81 [0.78-0.84], p<0.001) were associated with a decreased hazard of delisting.
CONCLUSIONS: In this study, LT candidates with Medicare or Medicaid had 20% increased risk of delisting due to death or clinical deterioration than those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population.