Use of Population-based Data to Demonstrate How Waitlist-based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care
Use of Population-based Data to Demonstrate How Waitlist-based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care
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DOI：
10.1111/ajt.13820
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发表时间：
2016-10-01
影响因子：
8.8
通讯作者：
Halpern, S. D.
中科院分区：
文献类型：
--
作者：
Goldberg, D. S.;French, B.;Halpern, S. D.
肝脏分配政策是通过它们如何影响等待名单上的患者来评估的，而不考虑所有未在等待名单上的终末期肝病（ESLD）患者的更广泛结果。我们使用两个具有全国代表性的数据库进行了一项回顾性队列研究：HealthCore（2006-2014）和五州医疗补助（加州、佛罗里达、纽约、俄亥俄州和宾夕法尼亚州; 2002-2009）。器官共享联合网络（UNOS）的联系使等待名单和移植相关结果的确定成为可能。我们纳入了年龄在18-75岁的ESLD（失代偿性肝硬化或肝细胞癌）患者，使用经验证的基于国际疾病分类第九版（ICD-9）的算法。在16824例ESLD HealthCore患者中，3年等待和移植发生率分别为15.8%（95%置信区间[CI]：15.0-16.6%）和8.1%（7.5-8.8%）。在67706名ESLD医疗补助患者中，3年等待和移植发生率分别为10.0%（9.7-10.4%）和6.7%（6.5-7.0%）。在HealthCore中，各州等待名单死亡率和移植率的绝对范围大于所有ESLD患者的相应范围（等待名单死亡率：13.6- 38.5%，ESLD 3年死亡率：48.9-62.0%;等待名单移植率：36.3- 72.7%，ESLD移植率：4.8-13.4%）。各州的等待名单死亡率和ESLD人口死亡率不呈正相关：rho =-0.06，p值= 0.83（HealthCore）; rho =-0.87，p值= 0.05（Medicaid）。在Medicaid中，等待名单和ESLD移植率呈弱正相关（rho = 0.36，p值= 0.55），但在HealthCore中呈正相关（rho = 0.73，p值= 0.001）。与基于人口的指标相比，基于等待名单的指标高估了肝移植的地理差异。
Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end-stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally representative databases: HealthCore (2006-2014) and five-state Medicaid (California, Florida, New York, Ohio and Pennsylvania; 2002-2009). United Network for Organ Sharing (UNOS) linkages enabled ascertainment of waitlist-and transplant-related outcomes. We included patients aged 18-75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated International Classification of Diseases, Ninth Revision (ICD-9)-based algorithms. Among 16 824 ESLD HealthCore patients, 3-year incidences of waitlisting and transplantation were 15.8% (95% confidence interval [CI] : 15.0-16.6%) and 8.1% (7.5-8.8%), respectively. Among 67 706 ESLD Medicaid patients, 3-year incidences of waitlisting and transplantation were 10.0% (9.7-10.4%) and 6.7% (6.5-7.0%), respectively. In HealthCore, the absolute ranges in states' waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6-38.5%, ESLD 3-year mortality: 48.9-62.0%; waitlist transplant rates: 36.3-72.7%, ESLD transplant rates: 4.8-13.4%). States' waitlist mortality and ESLD population mortality were not positively correlated: rho = -0.06, p-value = 0.83 (HealthCore); rho = -0.87, p-value = 0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (rho = 0.36, p-value = 0.55) but were positively correlated in HealthCore (rho = 0.73, p-value = 0.001). Compared to population-based metrics, waitlist-based metrics overestimate geographic disparities in access to liver transplantation.