National Healthcare Delivery Systems Influence Lung Transplant Outcomes for Cystic Fibrosis

Abstract

Successful lung transplantation (LTx) depends on multiple components of healthcare delivery and performance. Therefore, we conducted an international registry analysis to compare post‐LTx outcomes for cystic fibrosis (CF) patients using the UNOS registry in the United States and the National Health Service (NHS) Transplant Registry in the United Kingdom. Patients with CF who underwent lung or heart–lung transplantation in the United States or United Kingdom between January 1, 2000 and December 31, 2011 were included. The primary outcome was all‐cause mortality. Kaplan–Meier analysis and Cox proportional hazards regression evaluated the effect of healthcare system and insurance on mortality after LTx. 2,307 US LTx recipients and 451 individuals in the United Kingdom were included. 894 (38.8%) US LTx recipients had publically funded Medicare/Medicaid insurance. US private insurance and UK patients had improved median predicted survival compared with US Medicare/Medicaid recipients (p < 0.001). In multivariable Cox regression, US Medicare/Medicaid insurance was associated with worse survival after LTx (US private: HR0.78,0.68–0.90,p = 0.001 and UK: HR0.63,0.41–0.97, p = 0.03). This study in CF patients is the largest comparison of LTx in two unique health systems. Both the United States and United Kingdom have similar early survival outcomes, suggesting important dissemination of best practices internationally. However, the performance of US public insurance is significantly worse and may put patients at risk.

Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States

“…In Canada, universal healthcare provides all individuals with the opportunity to access medical services across the country; in the US, differing health insurance coverage impacts access to medical care and costs of care and is related to socioeconomic status (SES). (30;33) Indeed we observed health insurance status in the US had a differential effect on the risk of death for individuals living with CF compared to Canada. Interestingly, there was no statistically significant difference in risk of death among Canadians and those in the US with “other” insurance (which was comprised primarily of individuals with private coverage).…”

“…For instance, median survival post-lung transplant is longer in Canadian CF patients compared to published studies of US CF patients. (32) (33) Although the LAS has been associated with shorter waiting times and improved transplant survival(35), and the number of patients with CF listed for lung transplantation has increased since its implementation, the proportion who have received a transplant has decreased. (36) In addition, Merlo et al showed that CF patients transplanted since the LAS was implemented had a higher risk of death compared to CF patients transplanted in the pre-LAS period.…”

Socioeconomic status and health outcomes: cystic fibrosis as a model

“…Patients not completing high school and those residing in ZIP codes with lowest median household income also experienced higher odds (2.37 and 1.39, respectively) of not being accepted for lung transplant. Similarly, a registry analysis of CF patients who underwent lung transplantation in the United States or the United Kingdom between 2000 and 2011 showed that US Medicare/Medicaid insurance was associated with worse survival after lung transplantation compared to US private insurance and UK National Health System (p < 0.001) [130].…”

El trasplante pulmonar en la fibrosis quística y la influencia de la circulación extracorpórea

“…La publicación de Merlo y cols 249 , sobre la influencia de los seguros médicos en el TP por FQ, reporta que la necesidad de oxigenoterapia previa al TP es del 72.8 % en los pacientes de Reino Unido y del 83,8% en los Estados Unidos de Norteamerica.…”