Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
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DOI：
10.1001/jamanetworkopen.2019.10326
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发表时间：
2019-08-01
影响因子：
13.8
通讯作者：
Mehta, Neil
中科院分区：
文献类型：
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作者：
Gutin, Liat;Yao, Francis;Mehta, Neil
重要性肝细胞癌（HCC）患者在获得医疗保健方面存在有充分记录的种族/民族和社会经济差异;然而，关于保险类型与肝移植（LT）等待名单结果之间的关联的数据很少。这项单中心队列研究纳入了705名患有终末期肝病模型例外的成年HCC患者，并在2010年1月1日至2016年12月31日期间被纳入LT的等待名单。包括Kaiser Permanente医疗保险、其他私人医疗保险或公共医疗保险的患者。数据分析时间为2018年5月至2018年10月。主要结局和指标主要结局为入组后2年内LT等候名单脱落的累积发生率（基线）。次要结果包括竞争风险分析，以确定与等待名单结果相关的风险因素。（中位[四分位距]年龄，61 [57-65]岁; 537例[76.2%]男性）肝移植等候名单上的HCC患者，349例患者（49.5%）有Kaiser Permanente保险，157名患者（22.3%）有其他私人保险，199名患者（28.2%）有公共保险。中位（四分位距）随访时间为13.2（7.8-18.7）个月。不同保险类型的肿瘤特征相似。基线2年内因肿瘤进展或死亡而脱落的累积发生率为21.8%（95% CI，17.2%-26.7%）在Kaiser Permanente保险组中，25.5%在其他私人保险组中为35.5%（95%CI，18.6%-33.0%），在公共保险组中为35.5%（95%CI，28.3%-42.7%）（P < .001）。在Kaiser Permanente保险组中，基线2年内LT的累积发生率为67.3%（95%CI，61.2%-72.6%），其他私人保险组为64.1%（95%CI，55.2%-71.7%），公共保险组为48.5%（95%CI，40.4%-56.1%）（P <0.001）。在竞争风险多变量分析中，与参加Kaiser Permanente保险的患者相比，参加公共保险的患者与辍学风险增加相关（风险比[HR]，1.69 [95%CI，1.17-2.43]; P = 0.005），但参加其他私人保险的患者则不然（HR，1.40 [95%CI，0.94-2.08]; P = 0.10）。等候名单脱落与甲胎蛋白水平100 ng/mL或更高显著相关（HR，2.8 [95%CI，1.98-3.88]; P
IMPORTANCE There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC.OBJECTIVE To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance.DESIGN, SETTING, AND PARTICIPANTS This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018.MAIN OUTCOMES AND MEASURES The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes.RESULTS Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8%(95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5%(95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5%(95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3%(95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5%(95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P =.10). Waiting list dropout was also significantly associated with an a-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P