What Liver Transplant Outcomes Can Be Expected in the Uninsured Who Become Insured via the Affordable Care Act?

Glueckert, Lindsey; Redden, David T.; Thompson, Maxwell; Haque, A.; Gray, Stephen H.; Locke, Jayme E.; Eckhoff, Devin E.; Fouad, Mph Mona N.; DuBay, Derek A.

doi:10.1111/ajt.12244

Cited by 14 publications

(22 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…For example, HIV-infected individuals are disproportionately affected by poverty (9), which results in decreased access or utilization of health care, while transplant recipients are followed closely after transplantation, resulting in heightened medical surveillance. Further, in the U.S., HIV-infected people are less likely to have health insurance; one study of HIV-infected individuals in care reported that 28.4% were uninsured, compared to 2.6% of liver transplant recipients in another study (8;12). …”

Section: Discussionmentioning

confidence: 99%

Cancer stage at diagnosis in patients infected with the human immunodeficiency virus and transplant recipients

Shiels

Copeland

Goodman

et al. 2015

Cancer

View full text Add to dashboard Cite

Background It is unknown whether immunosuppression results in more aggressive, advanced stage cancers. As cancer stage is influenced both by tumor biology and medical surveillance, we assessed cancer stage in HIV-infected individuals and solid organ transplant recipients, two immunosuppressed groups with differences in healthcare utilization. Methods We used data on all cases of 15 cancer types, diagnosed during 1996–2010 in two studies that linked U.S. cancer registries to HIV and transplant registries. Odds ratios (ORs) for advanced (vs. local) disease were estimated comparing HIV and transplant populations to immunocompetent people in polytomous logistic regression models, adjusted for age, sex, race, registry and year. Results A total of 8,411 of 4.5 million cancer cases occurred in HIV-infected people, and 7,322 of 6.4 million cancer cases occurred in transplant recipients. Compared to immunocompetent people with cancer, HIV-infected people were more likely to be diagnosed with distant stage lung (OR=1.13), female breast (OR=1.99), and prostate cancers (OR=1.57), while transplant recipients had fewer distant stage lung (OR=0.54), female breast (OR=0.75) and prostate cancers (OR=0.72). Both immunosuppressed populations had a shift toward advanced stage melanoma (ORs: HIV=1.97; transplant=1.82) and bladder cancer (ORs: HIV=1.42; transplant=1.54). Conclusions Bladder cancer and melanoma were more likely to be diagnosed at non-local stage in both HIV-infected people and transplant recipients, suggesting a role of immunosuppression in their progression. Additionally, we observed a shift for some common cancers toward later stages in HIV-infected individuals and toward earlier stages in transplant recipients, consistent with differential access to medical care or surveillance.

show abstract

Section: Discussionmentioning

confidence: 99%

Cancer stage at diagnosis in patients infected with the human immunodeficiency virus and transplant recipients

Shiels

Copeland

Goodman

et al. 2015

Cancer

View full text Add to dashboard Cite

show abstract

“…(5–13) With introduction of the ACA, there will be more Medicaid beneficiaries who can access organ transplantation, and given prior reports of inferior outcomes among this population, (5, 7–9) transplant centers may encounter observed survival rates significantly lower than expected. In the context of the current regulatory environment, understanding the impact of implementation of the ACA on transplant outcomes is of paramount importance.…”

Section: Introductionmentioning

confidence: 99%

Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes

DuBay

MacLennan

Reed

et al. 2016

Journal of the American College of Surgeons

View full text Add to dashboard Cite

Background The number of Medicaid beneficiaries has increased under the Affordable Care Act (ACA), improving access to solid organ transplantation in this disadvantaged patient cohort. It is unclear what impact Medicaid expansion will have on transplant outcomes. We performed a retrospective cohort analysis to measure the frequency and variation in Medicaid transplantation, and post-transplant 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). Outcome measures included five-year post-transplant 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 transplants were performed than expected among Medicaid beneficiaries for all organs but liver [Observed/Expected ratios (95% CI): liver=1.21 (0.68, 1.90); heart=0.89 (0.44, 1.49); lung=0.57 (0.22, 1.06); renal=0.32 (0.08, 0.72)]. Medicaid transplant recipients were listed with more severe organ failure and experienced shorter transplant wait times. Post-transplant survival was lower in Medicaid patients compared to Private insurance for all organs. Post-transplant 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 to Privately insured beneficiaries. The more severe organ failure among Medicaid beneficiaries at the time of listing suggested a pattern of late referral, which may account for worse outcomes. Implementation of the ACA affords the opportunity to develop the necessary infrastructure to ensure timely transplant referrals and improve long-term outcomes in this vulnerable population.

show abstract

“…With no insurance data available >5 years after LT, the analysis was limited to patients transplanted in 2009‐2013. LT performed in the postexpansion period were not analyzed due to potential changes in the composition of patients referred for LT in states where Medicaid expansion made LT available to more patients . Patients' state of residence was recorded at transplantation and during follow‐up.…”

Section: Methodsmentioning

confidence: 99%

“…Posttransplant enrollment in Medicaid may be an option for LT recipients who remain unemployed or otherwise experience difficulties with access to care due to low income. The availability of Medicaid for low‐income adults has been enhanced by the Patient Protection and Affordable Care Act (ACA) of 2010, designed to expand Medicaid by allowing eligibility at higher income levels and extending eligibility to adults with no children . Because this expansion of Medicaid did not take effect earlier than January 1, 2014 in most participating states, its effects on LT are uncertain, and at this time, are largely speculative …”

mentioning

confidence: 99%

Medicaid enrollment after liver transplantation: Effects of medicaid expansion

et al. 2016

View full text Add to dashboard Cite

Liver transplantation (LT) recipients in the United States have low rates of paid employment, making some eligible for Medicaid public health insurance after transplant. We test whether recent expansions of Medicaid eligibility increased Medicaid enrollment and insurance coverage in this population. Patients of ages 18-59 years receiving first-time LTs in 2009-2013 were identified in the United Network for Organ Sharing registry and stratified according to insurance at transplantation (private versus Medicaid/Medicare). Posttransplant insurance status was assessed through June 2015. Difference-in-difference multivariate competing-risks models stratified on state of residence estimated effects of Medicaid expansion on Medicaid enrollment or use of uninsured care after LT. Of 12,837 patients meeting inclusion criteria, 6554 (51%) lived in a state that expanded Medicaid eligibility. Medicaid participation after LT was more common in Medicaidexpansion states (25%) compared to nonexpansion states (19%; P < 0.001). Multivariate analysis of 7279 patients with private insurance at transplantation demonstrated that after the effective date of Medicaid expansion (January 1, 2014), the hazard of posttransplant Medicaid enrollment increased in states participating in Medicaid expansion (hazard ratio [HR] 5 1.5; 95% confidence interval [CI] 5 1.1-2.0; P 5 0.01), but not in states opting out of Medicaid expansion (HR 5 0.8; 95% CI 5 0.5-1.3; P 5 0.37), controlling for individual characteristics and time-invariant state-level factors. No effects of Medicaid expansion on the use of posttransplant uninsured care were found, regardless of private or government insurance status at transplantation. Medicaid expansion increased posttransplant Medicaid enrollment among patients who had private insurance at transplantation, but it did not improve overall access to health insurance among LT recipients.

show abstract

What Liver Transplant Outcomes Can Be Expected in the Uninsured Who Become Insured via the Affordable Care Act?

Cited by 14 publications

References 18 publications

Cancer stage at diagnosis in patients infected with the human immunodeficiency virus and transplant recipients

Cancer stage at diagnosis in patients infected with the human immunodeficiency virus and transplant recipients

Insurance Type and Solid Organ Transplantation Outcomes: A Historical Perspective on How Medicaid Expansion Might Impact Transplantation Outcomes

Medicaid enrollment after liver transplantation: Effects of medicaid expansion

Contact Info

Product

Resources

About