Do funding sources influence long‐term patient survival in pediatric liver transplantation?

Abstract

Background Socioeconomic status has been associated with inferior outcomes after multiple surgical procedures, but has not been well studied with respect to pediatric liver transplantation. This study evaluated the impact of insurance status (as a proxy for socioeconomic status) on patient and allograft survival in pediatric first‐time liver transplant recipients. Methods Our retrospective analysis of the UNOS data base from January 2002 through September 2017 revealed 6997 pediatric patients undergoing first‐time isolated liver transplantation. A mixed Cox proportional hazards model adjusted for donor, recipient, and program characteristics determined the RR of insurance status on allograft and patient survival. All results were considered significant at P < .05. All statistical results were obtained using R version 3.5.1 and coxme version 2.2‐10. Results Medicaid status had a significant negative impact on long‐term survival after controlling for multiple covariates. Pediatric patients undergoing first‐time isolated liver transplantation with Medicaid insurance had a RR of 1.42 [confidence interval: 1.18‐1.60] of post‐transplant death. Conclusion Pediatric patients undergoing first‐time isolated liver transplantation have multiple risk factors that may impact long‐term survival. Having Medicaid insurance almost doubles the chances of dying post‐liver transplant. This patient population may require more global support post‐transplant to improve long‐term survival.

A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation

“…Dick et al, using the UNOS database, found that children aged younger than 18 years with Medicaid insurance had a relative risk of 1.42 of posttransplant mortality, further demonstrating that socioeconomic position impacts transplant outcomes. [ 33 ]…”

Reexamining the Impact of Insurance Type on Kidney Transplant Waitlist Status and Posttransplantation Outcomes in the United States After Implementation of the Affordable Care Act

“…21 However, as noted by Dick et al in similar work involving the pediatric liver transplant population, it is important to remember the limitations of healthcare systems in mitigating the social drivers of health, which require structural changes reliant on political advocacy, community organizing, and action (such as increasing minimum wage, access to affordable housing, access to education, etc). 22 Just as we and Medicaid expansion under the ACA, publicly insured KT recipients were significantly more likely to die than privately insured recipients (9.2% vs 4.0%, respectively; RR = 1.22, CI, 1.15-1.31). B, After the KAS revision and Medicaid expansion under the ACA, publicly insured KT recipients were significantly more likely to suffer allograft failure than privately insured recipients (5.8% vs 3.7%, respectively; RR = 1.10, CI, 1.03-1.29).…”

“…21 However, as noted by Dick et al in similar work involving the pediatric liver transplant population, it is important to remember the limitations of healthcare systems in mitigating the social drivers of health, which require structural changes reliant on political advocacy, community organizing, and action (such as increasing minimum wage, access to affordable housing, access to education, etc). 22 Just as we expect evidence-based treatments for individual diseases, we need evidence-based policies and solutions to systemic health inequities. Physician and patient voices, often via collective organizations, can be valuable and influential in this realm.…”

State of pediatric liver transplantation in the United States and achieving zero wait list mortality with ideal outcomes: A statement from the Starzl Network for Excellence in Pediatric Transplant Surgeon's Working Group

“…25 LDLT has recently been associated with an improved patient survival when compared with whole liver transplant 21 and is associated with a lower incidence of acute cellular rejection. 20 Patients who received an LDLT were more likely to have private insurance, 26 and patients with public insurance are almost twice as likely to die after a liver transplant. 27 Although it has been shown that all race and ethnic groups have comparable posttransplant outcomes, higher rates of death and graft loss, higher rates of wait list mortality, and a lesser likelihood of obtaining exception points have been noted in individuals with public insurance.…”