title: Insurance and education predict long-term survival after orthotopic heart transplantation in the United States.
abstract: BACKGROUND
  Insurance status and education are known to affect health outcomes. However, their importance in orthotopic heart transplantation (OHT) is unknown. The United Network for Organ Sharing (UNOS) database provides a large cohort of OHT recipients in which to evaluate the effect of insurance and education on survival.
  
  
  METHODS
  UNOS data were retrospectively reviewed to identify adult primary OHT recipients (1997 to 2008). Patients were stratified by insurance at the time of transplantation (private/self-pay, Medicare, Medicaid, and other) and college education. All-cause mortality was examined using multivariable Cox proportional hazard regression incorporating 15 variables. Survival was modeled using the Kaplan-Meier method.
  
  
  RESULTS
  Insurance for 20,676 patients was distributed as follows: private insurance/self-pay, 12,298 (59.5%); Medicare, 5,227 (25.3%); Medicaid, 2,320 (11.2%); and "other" insurance, 831 (4.0%). Educational levels were recorded for 15,735 patients (76.1% of cohort): 7,738 (49.2%) had a college degree. During 53 ± 41 months of follow-up, 6,125 patients (29.6%) died (6.7 deaths/100 patient-years). Survival differed by insurance and education. Medicare and Medicaid patients had 8.6% and 10.0% lower 10-year survival, respectively, than private/self-pay patients. College-educated patients had 7.0% higher 10-year survival. On multivariable analysis, college education decreased mortality risk by 11%. Medicare and Medicaid increased mortality risk by 18% and 33%, respectively (p ≤ 0.001).
  
  
  CONCLUSIONS
  Our study examining insurance and education in a large cohort of OHT patients found that long-term mortality after OHT is higher in Medicare/Medicaid patients and in those without a college education. This study points to potential differences in the care of OHT patients based on education and insurance status.
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
authors.forename: Jeremiah G
authors.initials: JG
authors.lastname: Allen
authors.forename: Eric S
authors.initials: ES
authors.lastname: Weiss
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Russell
authors.forename: William A
authors.initials: WA
authors.lastname: Baumgartner
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
mesh_terms: D000328:Adult; D004522:Educational Status; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000191:economics / Q000401:mortality*; D016027:Heart Transplantation / Q000191:economics / Q000401:mortality*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology