title: 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.
authors: Divisions of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD.|The Bloomberg School of Public Health, The Johns Hopkins Medical Institutions, Baltimore, MD.
authors: C A
authors: CA
authors: Merlo
authors: Department of Cardiothoracic Transplantation and Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.
authors: S C
authors: SC
authors: Clark
authors: Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD.
authors: G J
authors: GJ
authors: Arnaoutakis
authors: North West Heart Centre and The Transplant Centre, University Hospital of South Manchester, Manchester, United Kingdom.
authors: N
authors: N
authors: Yonan
authors: Papworth Hospitals, NHS Trust Cambridge, Cambridge, United Kingdom.
authors: D
authors: D
authors: Thomas
authors: Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Middlesex, United Kingdom.
authors: A
authors: A
authors: Simon
authors: Department of Heart and Lung Transplantation, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
authors: R
authors: R
authors: Thompson
authors: Department of Heart and Lung Transplantation, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
authors: H
authors: H
authors: Thomas
authors: Divisions of Pulmonary and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD.
authors: J
authors: J
authors: Orens
authors: Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD.
authors: A S
authors: AS
authors: Shah
mesh_terms: D000328:Adult; D015331:Cohort Studies; D003550:Cystic Fibrosis / Q000401:mortality* / Q000601:surgery*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration* / Q000592:standards; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000401:mortality*; D006801:Humans; D007390:International Agencies; D016040:Lung Transplantation / Q000401:mortality*; D008297:Male; D009313:National Health Programs / Q000458:organization & administration* / Q000592:standards; D011183:Postoperative Complications; D011379:Prognosis; D011787:Quality of Health Care; D012042:Registries; D012307:Risk Factors; D015996:Survival Rate; D006113:United Kingdom; D014481:United States
keywords: clinical research / practice; epidemiology; health services and outcomes research; insurance; lung transplantation / pulmonology; organ transplantation in general; quality of care / care delivery