Medicare immunosuppressant coverage and access to kidney transplantation: a retrospective national cohort study.
BACKGROUND
In December 2000, Medicare eliminated time limitations in immunosuppressant coverage after kidney transplant for beneficiaries age ≥65 and those who were disabled. This change did not apply to younger non-disabled beneficiaries who qualified for Medicare only because of their end-stage renal disease (ESRD). We sought to examine access to waitlisting for kidney transplantation in a cohort spanning this policy change.


METHODS
This was a retrospective cohort analysis of 241,150 Medicare beneficiaries in the United States Renal Data System who initiated chronic dialysis between 1/1/96 and 11/30/03. We fit interrupted time series Cox proportional hazard models to compare access to kidney transplant waitlist within 12 months of initiating chronic dialysis by age/disability status, accounting for secular trends.


RESULTS
Beneficiaries age <65 who were not disabled were less likely to be waitlisted after the policy change (hazard ratio (HR) for the later vs. earlier period, 0.93, p = 0.002), after adjusting for sociodemographic factors, co-morbid conditions, income, and ESRD network. There was no evidence of secular trend in this group (HR per year, 1.00, p = 0.989). Likelihood of being waitlisted among those age ≥65 or disabled increased steadily throughout the study period (HR per year, 1.04, p < 0.001), but was not clearly affected by the policy change (HR for the immediate effect of policy change, 0.93, p = 0.135).


CONCLUSIONS
The most recent extension in Medicare immunosuppressant coverage appears to have had little impact on the already increasing access to waitlisting among ≥65/ disabled beneficiaries eligible for the benefit but may have decreased access for younger, non-disabled beneficiaries who were not. The potential ramifications of policies on candidacy appeal for access to kidney transplantation should be considered.
Division of Nephrology, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA. grubbsv@medsfgh.ucsf.edu
Vanessa
V
Grubbs
Laura C
LC
Plantinga
Eric
E
Vittinghoff
Ann M
AM
O'Hare
R Adams
RA
Dudley
D000328:Adult; D000368:Aged; D004185:Disability Evaluation; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007166:Immunosuppressive Agents / Q000191:economics*; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000208:ethnology / Q000601:surgery*; D016030:Kidney Transplantation; D008297:Male; D006278:Medicare / Q000191:economics*; D008875:Middle Aged; D018579:Patient Selection; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists
D007166:Immunosuppressive Agents