Insurance Type and Solid Organ Transplantation Outcomes

A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes

Derek A. DuBay, Paul A. MacLennan, Rhiannon D. Reed, Brittany A. Shelton, David T. Redden, Mona Fouad, Michelle Martin, Stephen H. Gray, Jared A. White, Devin E. Eckhoff, Jayme E. Locke

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

Background The number of Medicaid beneficiaries has increased under the Affordable Care Act, improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplantation outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation and post-transplantation survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n = 169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (private, Medicare or Medicaid). Outcomes measures included 5-year post-transplantation survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplantations were performed than expected among Medicaid beneficiaries for all organs except liver (liver: observed to expected ratio = 1.21; 95% CI, 0.68–1.90; heart: observed to expected ratio = 0.89; 95% CI, 0.44–1.49; lung: observed to expected ratio = 0.57; 95% CI, 0.22–1.06; renal: observed to expected ratio = 0.32; 95% CI, 0.08–0.72). Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplantation survival was lower in Medicaid patients compared with private insurance for all organs. Post-transplantation survival in Medicaid patients was similar to Medicare patients for heart, liver, and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared with privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing, suggested a pattern of late referral, which might account for worse outcomes. Implementation of the Affordable Care Act gives the opportunity to develop the necessary infrastructure to ensure timely transplantation referrals and improve long-term outcomes in this vulnerable population.

Original languageEnglish (US)
Pages (from-to)611-620.e4
JournalJournal of the American College of Surgeons
Volume223
Issue number4
DOIs
StatePublished - Oct 1 2016

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Medicaid
Organ Transplantation
Insurance
Transplantation
Survival
Patient Protection and Affordable Care Act
Liver
Vulnerable Populations
Medicare
Transplants
Kidney
Lung
Referral and Consultation
Insurance Coverage
Proportional Hazards Models
Registries
Cohort Studies
Outcome Assessment (Health Care)
Transplant Recipients
Tissue Donors

All Science Journal Classification (ASJC) codes

  • Surgery

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Insurance Type and Solid Organ Transplantation Outcomes : A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes. / DuBay, Derek A.; MacLennan, Paul A.; Reed, Rhiannon D.; Shelton, Brittany A.; Redden, David T.; Fouad, Mona; Martin, Michelle; Gray, Stephen H.; White, Jared A.; Eckhoff, Devin E.; Locke, Jayme E.

In: Journal of the American College of Surgeons, Vol. 223, No. 4, 01.10.2016, p. 611-620.e4.

Research output: Contribution to journalArticle

DuBay, Derek A. ; MacLennan, Paul A. ; Reed, Rhiannon D. ; Shelton, Brittany A. ; Redden, David T. ; Fouad, Mona ; Martin, Michelle ; Gray, Stephen H. ; White, Jared A. ; Eckhoff, Devin E. ; Locke, Jayme E. / Insurance Type and Solid Organ Transplantation Outcomes : A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes. In: Journal of the American College of Surgeons. 2016 ; Vol. 223, No. 4. pp. 611-620.e4.
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title = "Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes",
abstract = "Background The number of Medicaid beneficiaries has increased under the Affordable Care Act, improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplantation outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation and post-transplantation survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n = 169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (private, Medicare or Medicaid). Outcomes measures included 5-year post-transplantation survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6{\%} of all organ transplant recipients. Fewer transplantations were performed than expected among Medicaid beneficiaries for all organs except liver (liver: observed to expected ratio = 1.21; 95{\%} CI, 0.68–1.90; heart: observed to expected ratio = 0.89; 95{\%} CI, 0.44–1.49; lung: observed to expected ratio = 0.57; 95{\%} CI, 0.22–1.06; renal: observed to expected ratio = 0.32; 95{\%} CI, 0.08–0.72). Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplantation survival was lower in Medicaid patients compared with private insurance for all organs. Post-transplantation survival in Medicaid patients was similar to Medicare patients for heart, liver, and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared with privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing, suggested a pattern of late referral, which might account for worse outcomes. Implementation of the Affordable Care Act gives the opportunity to develop the necessary infrastructure to ensure timely transplantation referrals and improve long-term outcomes in this vulnerable population.",
author = "DuBay, {Derek A.} and MacLennan, {Paul A.} and Reed, {Rhiannon D.} and Shelton, {Brittany A.} and Redden, {David T.} and Mona Fouad and Michelle Martin and Gray, {Stephen H.} and White, {Jared A.} and Eckhoff, {Devin E.} and Locke, {Jayme E.}",
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T1 - Insurance Type and Solid Organ Transplantation Outcomes

T2 - A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes

AU - DuBay, Derek A.

AU - MacLennan, Paul A.

AU - Reed, Rhiannon D.

AU - Shelton, Brittany A.

AU - Redden, David T.

AU - Fouad, Mona

AU - Martin, Michelle

AU - Gray, Stephen H.

AU - White, Jared A.

AU - Eckhoff, Devin E.

AU - Locke, Jayme E.

PY - 2016/10/1

Y1 - 2016/10/1

N2 - Background The number of Medicaid beneficiaries has increased under the Affordable Care Act, improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplantation outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation and post-transplantation survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n = 169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (private, Medicare or Medicaid). Outcomes measures included 5-year post-transplantation survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplantations were performed than expected among Medicaid beneficiaries for all organs except liver (liver: observed to expected ratio = 1.21; 95% CI, 0.68–1.90; heart: observed to expected ratio = 0.89; 95% CI, 0.44–1.49; lung: observed to expected ratio = 0.57; 95% CI, 0.22–1.06; renal: observed to expected ratio = 0.32; 95% CI, 0.08–0.72). Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplantation survival was lower in Medicaid patients compared with private insurance for all organs. Post-transplantation survival in Medicaid patients was similar to Medicare patients for heart, liver, and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared with privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing, suggested a pattern of late referral, which might account for worse outcomes. Implementation of the Affordable Care Act gives the opportunity to develop the necessary infrastructure to ensure timely transplantation referrals and improve long-term outcomes in this vulnerable population.

AB - Background The number of Medicaid beneficiaries has increased under the Affordable Care Act, improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplantation outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation and post-transplantation survival in Medicaid patients. Study Design Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n = 169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (private, Medicare or Medicaid). Outcomes measures included 5-year post-transplantation survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors. Results Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplantations were performed than expected among Medicaid beneficiaries for all organs except liver (liver: observed to expected ratio = 1.21; 95% CI, 0.68–1.90; heart: observed to expected ratio = 0.89; 95% CI, 0.44–1.49; lung: observed to expected ratio = 0.57; 95% CI, 0.22–1.06; renal: observed to expected ratio = 0.32; 95% CI, 0.08–0.72). Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplantation survival was lower in Medicaid patients compared with private insurance for all organs. Post-transplantation survival in Medicaid patients was similar to Medicare patients for heart, liver, and renal but lower in lung. Conclusions Medicaid organ transplant beneficiaries had significantly lower survival compared with privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing, suggested a pattern of late referral, which might account for worse outcomes. Implementation of the Affordable Care Act gives the opportunity to develop the necessary infrastructure to ensure timely transplantation referrals and improve long-term outcomes in this vulnerable population.

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