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Increased Mortality in Adult Cystic Fibrosis Patients with Medicaid Insurance Awaiting Lung Transplantation

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Abstract

Purpose

Cystic fibrosis (CF) is a progressive disease resulting in end-stage lung disease. Lung transplantation (LTx) is an important consideration in these patients. Studies have suggested greater post-LTx mortality among CF patients with public insurance. We evaluated the influence of insurance status on survival among CF patients during their time on the LTx waitlist.

Methods

Adult LTx candidates diagnosed with CF and listed since the implementation of the lung allocation score, from May 2005 until September 2013, were identified in the United Network for Organ Sharing database. Waitlist mortality was compared across projected primary payment type (private insurance or self-pay; Medicaid; Medicare) using Kaplan–Meier functions and Fine–Gray competing-risks survival analysis, accounting for the competing risk of transplantation.

Results

1770 LTx candidates with CF were included in univariate survival analyses, with Medicaid increasing waitlist mortality hazard relative to private insurance (HR 2.28; 95 % CI 1.62, 3.21; p < 0.001) and relative to Medicare (HR 2.23; 95 % CI 1.43, 3.48; p < 0.001). A multivariable competing-risks model confirmed greater waitlist mortality among Medicaid patients relative to private insurance (HR 2.57; 95 % CI 1.56, 4.23; p < 0.001) or patients with Medicare (HR 4.02; 95 % CI 1.98, 8.17; p < 0.001) after adjusting for potential confounders. No differences in waitlist survival were found between Medicare and private insurance.

Conclusions

CF patients with Medicaid insurance have higher risk of death while awaiting LTx when compared to patients with Medicare or private insurance. The impact of insurance status on survival in this population begins before LTx and compounds the disparities previously observed in post-transplant outcomes.

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Author Contribution

Katelyn Krivchenia: Conception and design, acquisition of data, interpretation of data, drafting of the manuscript. Dmitry Tumin: Conception and design, statistical analysis, interpretation of data, revision of the manuscript. Joseph D. Tobias: Interpretation of data, revision of the manuscript. Don Hayes, Jr.: Conception and design, acquisition of data, interpretation of data, revision of the manuscript.

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Authors and Affiliations

  1. Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Ave, Columbus, OH, 43210, USA

    Dmitry Tumin & Don Hayes Jr.

  2. Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, 370 W. 9th Ave, Columbus, OH, 43210, USA

    Joseph D. Tobias

  3. Department of Internal Medicine, The Ohio State University College of Medicine, 370 W. 9th Ave, Columbus, OH, 43210, USA

    Don Hayes Jr.

  4. Department of Surgery, The Ohio State University College of Medicine, 370 W. 9th Ave, Columbus, OH, 43210, USA

    Don Hayes Jr.

  5. Center for the Epidemiological Study of Organ Failure and Transplantation, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205, USA

    Katelyn Krivchenia, Dmitry Tumin, Joseph D. Tobias & Don Hayes Jr.

  6. Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205, USA

    Dmitry Tumin & Joseph D. Tobias

  7. Section of Pulmonary Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205, USA

    Katelyn Krivchenia & Don Hayes Jr.

Authors
  1. Katelyn Krivchenia
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  2. Dmitry Tumin
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  3. Joseph D. Tobias
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  4. Don Hayes Jr.
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Correspondence to Katelyn Krivchenia.

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Krivchenia, K., Tumin, D., Tobias, J.D. et al. Increased Mortality in Adult Cystic Fibrosis Patients with Medicaid Insurance Awaiting Lung Transplantation. Lung 194, 799–806 (2016). https://doi.org/10.1007/s00408-016-9927-7

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  • DOI: https://doi.org/10.1007/s00408-016-9927-7

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