Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes.
Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes.
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DOI：
10.1161/circoutcomes.119.006284
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发表时间：
2020-06
期刊：
影响因子：
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通讯作者：
Joynt Maddox KE
中科院分区：
文献类型：
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作者：
Wang X;Luke AA;Vader JM;Maddox TM;Joynt Maddox KE
对于不适合心脏移植或正在等待合适捐赠者的患者来说，左心室辅助装置（LVAD）治疗是一种越来越可行的替代方案。我们的目的是确定性别、种族/民族、保险范围和社区收入与LVAD植入的可及性/结局之间是否存在关联。我们进一步分析了在扩大医疗补助的州与没有扩大医疗补助的州，LVAD的获得是否有所改善。回顾性队列研究，使用国家住院患者数据库识别2012-2015年因心力衰竭、心源性休克或LVAD植入而入院的18-85岁患者。对年龄、上述所有社会人口学因素、医学合并症和医院随机效应进行了Logistic回归分析，以量化相关社会人口学群体接受LVAD的几率以及接受LVAD的条件性结局。共纳入925，770例患者; 3，972例（0.43%）接受LVAD。校正年龄、合并症和医院影响后，女性（校正OR（aOR）0.45 [0.41-0.49]）、黑人患者（aOR 0.83 [0.74-0.92]）和西班牙裔患者（aOR 0.74 [0.64-0.87]）接受LVAD的可能性低于白人。医疗保险（aOR 0.79 [0.72-0.86]），医疗补助（aOR 0.52 [0.46-0.58]）和未保险的患者（aOR 0.17 [0.11-0.25]）接受LVAD的可能性低于私人保险，低收入邮政编码的患者接受LVAD的可能性低于高收入地区的患者（aOR 0.71 [0.65-0.77]）。在接受LVAD的患者中，女性（aOR 1.78 [1.38-2.30]）、未知种族或除白色、黑人或西班牙裔以外的种族的患者（aOR 1.97 [1.42-2.74]）和未投保的患者（aOR 4.86 [1.92-12.28]）的院内死亡率较高。医疗补助的扩大与LVAD植入的增加无关。在LVAD植入的可及性和结局方面存在有意义的社会人口差异。医疗补助的扩大与LVAD率的增加无关。
Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between gender, race/ethnicity, insurance coverage, and neighborhood income, and access to / outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did vs did not expand Medicaid. Retrospective cohort study using State Inpatient Databases to identify patients 18–85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012–2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925,770 patients were included; 3,972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted OR (aOR) 0.45 [0.41–0.49]), black patients (aOR 0.83 [0.74–0.92]) and Hispanic patients (aOR 0.74 [0.64–0.87]) were less likely to receive LVADs than whites. Medicare (aOR 0.79 [0.72–0.86]), Medicaid (aOR 0.52 [0.46–0.58]), and uninsured patients (aOR 0.17 [0.11–0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher-income areas (aOR 0.71 [0.65–0.77]). Among those who received LVADs, women (aOR 1.78 [1.38–2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR 1.97 [1.42–2.74]), and uninsured patients (aOR 4.86 [1.92–12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation. There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.