title: Impact of Insurance Type on Initial Rejection Post Heart Transplant.
abstract: BACKGROUND
  Heart transplantation allocation is often restricted from patients with low socioeconomic status (SES) due to concern for worse outcomes. We hypothesised that comorbidities would have a greater impact on risk of severe rejection post-orthotopic heart transplant than would Medicaid insurance and Median Household Income (MHI).
  
  
  METHODS
  A retrospective study of 171 patients who underwent orthotopic heart transplant between 7/1999-11/2013 at our facility were followed until 9/2014 for rejection hospitalisations or death. Survival and multivariable analyses with adjustment for age, race, and gender were performed to estimate the risk of severe cellular rejection, ≥2r (hazard ratio [HR], 95% confidence interval [CI]).
  
  
  RESULTS
  Eighteen per cent of patients had Medicaid, and 72% of patients had low or medium MHI. Severe rejection occurred in 23% of patients. In the univariable analysis, Medicaid and diabetes were associated with increased risk of rejection while age >60 years, Caucasian race, and male sex were associated with reduced risk [Medicaid 2.32(1.20,4.51), diabetes 2.49(1.09,5.69), age 0.41(0.20,0.84), Caucasian 0.44(0.21,0.93), male 0.49(0.26,0.92)]. Median Household Income had no correlation [MHI 0.79(0.51,1.23)]. In the multivariable adjusted model, Medicaid was not associated with rejection [1.65(0.79,3.41)]; diabetes was strongly associated with risk of severe rejection [3.9(1.59,9.39)], and age >60 years was associated with risk reduction [0.42(0.20,0.82)].
  
  
  CONCLUSIONS
  Medicaid insurance and MHI were not associated with increased risk of severe cellular rejection requiring hospitalisation post-orthotopic heart transplant in the adjusted model. Rather the presence of diabetes and age ≤60 years were associated with increased risk.
authors.affiliation: Division of Cardiology, University of Colorado Anschutz Medical Center, Aurora, Colorado. Electronic address: Khadijah.breathett@ucdenver.edu.
authors.forename: Khadijah
authors.initials: K
authors.lastname: Breathett
authors.affiliation: Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.
authors.forename: Shannon
authors.initials: S
authors.lastname: Willis
authors.affiliation: Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio.
authors.forename: Randi E
authors.initials: RE
authors.lastname: Foraker
authors.affiliation: Division of Cardiology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
authors.forename: Sakima
authors.initials: S
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D005260:Female; D006084:Graft Rejection / Q000191:economics / Q000401:mortality / Q000601:surgery; D016027:Heart Transplantation / Q000191:economics; D006801:Humans; D007341:Insurance; D008297:Male; D008484:Medicaid; D008875:Middle Aged; D012307:Risk Factors; D012959:Socioeconomic Factors; D014481:United States
keywords: Diabetes; Outcomes; Socioeconomic status