Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes
Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes
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DOI：
10.1016/j.jamcollsurg.2016.07.004
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发表时间：
2016-10-01
影响因子：
5.2
通讯作者：
Locke, Jayme E.
中科院分区：
文献类型：
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作者：
DuBay, Derek A.;MacLennan, Paul A.;Locke, Jayme E.
背景：根据《平价医疗法案》，医疗补助受益人的数量有所增加，改善了这一弱势患者群体获得实体器官移植的机会。目前还不清楚医疗补助计划的扩大会对移植结果产生什么影响。我们进行了一项回顾性队列分析，以测量医疗补助患者移植的频率和变化以及移植后的生存率。研究设计：对2002年至2011年间报告给移植受者科学登记处的成人心脏、肺、肝和肾移植受者（n = 169,194）进行鉴定。移植接受者根据保险状况（私人、医疗保险或医疗补助）进行分类。结果测量包括移植后5年生存率，用Kaplan-Meier曲线总结并比较log-rank检验。使用器官特异性Cox比例风险模型来调整供体和受体因素。结果：医疗补助患者占所有器官移植受者的8.6%。在医疗补助受益人中，除肝脏外，所有器官的移植数量少于预期（肝脏：观察到的预期比= 1.21;95% CI, 0.68-1.90；心脏：观察到的预期比= 0.89;95% CI, 0.44-1.49；肺：观察到的预期比= 0.57;95% CI, 0.22-1.06；肾脏：观察到的预期比= 0.32;95% CI, 0.08-0.72）。医疗补助移植受者的器官衰竭更严重，移植等待时间更短。与所有器官的私人保险相比，医疗补助患者的移植后生存率较低。医疗补助患者的心脏、肝脏和肾脏移植后生存率与医疗保险患者相似，但肺移植后生存率较低。结论：与私人保险受益人相比，医疗补助器官移植受益人的生存率显著降低。在医疗补助受益人中，更严重的器官衰竭在上市时，表明了一种延迟转诊的模式，这可能是导致更糟糕结果的原因。《平价医疗法案》的实施为发展必要的基础设施提供了机会，以确保及时的移植转诊，并改善这一弱势群体的长期预后。(C) 2016年由美国外科医师学会发布。Elsevier Inc.出版。版权所有。)
BACKGROUND: The number of Medicaid beneficiaries has increased under the Affordable Care Act, improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplantation outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation and post-transplantation survival in Medicaid patients.STUDY DESIGN: Adult heart, lung, liver, and renal transplant recipients between 2002 and 2011 (n = 169,194) reported to the Scientific Registry of Transplant Recipients were identified. Transplant recipients were classified based on insurance status (private, Medicare or Medicaid). Outcomes measures included 5-year post-transplantation survival, summarized using Kaplan-Meier curves and compared with log-rank tests. Organ-specific Cox proportional hazards models were used to adjust for donor and recipient factors.RESULTS: Medicaid patients comprised 8.6% of all organ transplant recipients. Fewer transplantations were performed than expected among Medicaid beneficiaries for all organs except liver (liver: observed to expected ratio = 1.21; 95% CI, 0.68-1.90; heart: observed to expected ratio = 0.89; 95% CI, 0.44-1.49; lung: observed to expected ratio = 0.57; 95% CI, 0.22-1.06; renal: observed to expected ratio = 0.32; 95% CI, 0.08-0.72). Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplantation survival was lower in Medicaid patients compared with private insurance for all organs. Post-transplantation survival in Medicaid patients was similar to Medicare patients for heart, liver, and renal but lower in lung.CONCLUSIONS: Medicaid organ transplant beneficiaries had significantly lower survival compared with privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing, suggested a pattern of late referral, which might account for worse outcomes. Implementation of the Affordable Care Act gives the opportunity to develop the necessary infrastructure to ensure timely transplantation referrals and improve long-term outcomes in this vulnerable population. (C) 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)