Health Insurance Trajectories and Long-Term Survival After Heart Transplantation

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. (Circ Cardiovasc Qual Outcomes. 2016;9:576-584.

How to obtain and maintain favorable results after heart transplantation: keys to success?

“…The effect of a well deployed social security system with a compulsory health insurance coverage, providing full reimbursement of immunosuppressive and other drugs, has not been studied extensively in heart recipients (19)(20)(21)(22). It seems logical that these facilities, present in our country, decrease the risk of non-adherence and postponing medical help.…”

“…Until the end of 2015, 648 transplantations were performed in 615 patients, resulting in an average annual transplantation rate of 23 (range, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. Thirty recipients received a second donor heart and one patient was transplanted three times.…”

Insurance Coverage and Heart Transplant Outcomes

“…Limitations in the work by Tumin et al 19 are present and are highlighted by recent work by these investigators. 18 Foraker et al, 18 in a recent analysis of the UNOS database, examined the influence of private or public health insurance coverage on 1-year and long-term survival after heart transplantation.…”

“…Addressing this issue, Tumin et al 19 examined the influence of health insurance trajectories or transitions on long-term survival after heart transplantation. The investigators examined data from the United Network for Organ Sharing (UNOS) registry and identified 10 298 first-time heart transplant recipients between the ages 18 and 64 years from July 2006 through December 2013.…”

“…The work of Tumin et al 19 and others has identified an important association between public health insurance coverage and inferior heart transplantation outcomes. Significant opportunities exist to improve the current system of public healthcare coverage for patients requiring organ transplantation to eliminate the inequities in patient outcomes.…”