Change in Health Insurance Coverage After Liver Transplantation Can Be Associated with Worse Outcomes

  • Clifford Akateh
  • Dmitry Tumin
  • Eliza W. Beal
  • Khalid Mumtaz
  • Joseph D. Tobias
  • Don HayesJr.
  • Sylvester M. Black
Original Article

Abstract

Background

Health insurance coverage changes for many patients after liver transplantation, but the implications of this change on long-term outcomes are unclear.

Aims

To assess post-transplant patient and graft survival according to change in insurance coverage within 1 year of transplantation.

Methods

We queried the United Network for Organ Sharing for patients between ages 18–64 years undergoing liver transplantation in 2002–2016. Patients surviving > 1 year were categorized by insurance coverage at transplantation and the 1-year transplant anniversary. Multivariable Cox regression characterized the association between coverage pattern and long-term patient or graft survival.

Results

Among 34,487 patients in the analysis, insurance coverage patterns included continuous private coverage (58%), continuous public coverage (29%), private to public transition (8%) and public to private transition (4%). In multivariable analysis of patient survival, continuous public insurance (HR 1.29, CI 1.22, 1.37, p < 0.001), private to public transition (HR 1.17, CI 1.07, 1.28, p < 0.001), and public to private transition (HR 1.14, CI 1.00, 1.29, p = 0.044), were associated with greater mortality hazard, compared to continuous private coverage. After disaggregating public coverage by source, mortality hazard was highest for patients transitioning from private insurance to Medicaid (HR vs. continuous private coverage = 1.32; 95% CI 1.14, 1.52; p < 0.001). Similar differences by insurance category were found for death-censored graft failure.

Conclusion

Post-transplant transition to public insurance coverage is associated with higher risk of adverse outcomes when compared to retaining private coverage.

Keywords

Liver transplantation Graft survival Human Medicaid Survival Insurance 

Abbreviations

LT

Liver transplantation

ESLD

End-stage liver disease

MELD

Model for end-stage liver disease

ACA

Patient Protection and Affordable Care Act

US

United States of America

UNOS

United Network for Organ Sharing

ANOVA

Analysis of variance

TIPSS

Transjugular intrahepatic portosystemic shunt

DRI

Donor risk index

LOS

Length of stay

HR

Hazard ratios

CI

Confidence interval

ACS

American College of Surgeons

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

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Supplementary material 1 (DOCX 63 kb)
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Supplementary material 2 (DOCX 25 kb)
10620_2018_5031_MOESM3_ESM.docx (32 kb)
Supplementary material 3 (DOCX 31 kb)
10620_2018_5031_MOESM4_ESM.docx (24 kb)
Supplementary material 4 (DOCX 23 kb)

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of General and Gastrointestinal Surgery, Department of SurgeryOhio State University Wexner Medical CenterColumbusUSA
  2. 2.Division of Transplantation, Department of SurgeryOhio State University Wexner Medical CenterColumbusUSA
  3. 3.Division of Gastroenterology, Hepatology and Nutrition, Department of Internal MedicineOhio State University Wexner Medical CenterColumbusUSA
  4. 4.Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal MedicineOhio State University Wexner Medical CenterColumbusUSA
  5. 5.Section of Pulmonary Medicine, Department of PediatricsNationwide Children’s HospitalColumbusUSA
  6. 6.Department of Anesthesiology and Pain MedicineNationwide Children’s HospitalColumbusUSA
  7. 7.Department of Anesthesiology and Pain MedicineOhio State University Wexner Medical CenterColumbusUSA
  8. 8.Department of PediatricsOhio State University College of MedicineColumbusUSA
  9. 9.Ohio State University Wexner Medical Center - Faculty TowerColumbusUSA

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