Health Insurance Trajectories and Long-Term Survival After Heart Transplantation.
Health insurance status at heart transplantation influences recipient survival, but implications of change in insurance for long-term outcomes are unclear.



Adults aged 18 to 64 receiving first-time orthotopic heart transplants between July 2006 and December 2013 were identified in the United Network for Organ Sharing registry. Patients surviving >1 year were categorized according to trajectory of insurance status (private compared with public) at wait listing, transplantation, and 1-year follow-up. The most common insurance trajectories were continuous private coverage (44%), continuous public coverage (27%), and transition from private to public coverage (11%). Among patients who survived to 1 year (n=9088), continuous public insurance (hazard ratio =1.36; 95% confidence interval 1.19, 1.56; P<0.001) and transition from private to public insurance (hazard ratio =1.25; 95% confidence interval 1.04, 1.50; P=0.017) were associated with increased mortality hazard relative to continuous private insurance. Supplementary analyses of 11 247 patients included all durations of post-transplant survival and examined post-transplant private-to-public and public-to-private transitions as time-varying covariates. In these analyses, transition from private to public insurance was associated with increased mortality hazard (hazard ratio =1.25; 95% confidence interval 1.07, 1.47; P=0.005), whereas transition from public to private insurance was associated with lower mortality hazard (hazard ratio =0.78; 95% confidence interval 0.62, 0.97; P=0.024).



Transition from private to public insurance after heart transplantation is associated with worse long-term outcomes, compounding disparities in post-transplant survival attributed to insurance status at transplantation. By contrast, post-transplant gain of private insurance among patients receiving publicly funded heart transplants was associated with improved outcomes.
From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH. tumin.1@osu.edu.
Dmitry
D
Tumin
From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH.
Randi E
RE
Foraker
From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH.
Sakima
S
Smith
From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH.
Joseph D
JD
Tobias
From the Departments of Pediatrics (D.T., D.H.), Anesthesiology (J.D.T.), Internal Medicine (R.E.F., S.S., D.H.), and Surgery (D.H.), The Ohio State University College of Medicine, Columbus; Division of Epidemiology, The Ohio State University College of Public Health, Columbus (R.E.F.); Center for the Epidemiological Study of Organ Failure and Transplantation (D.T., R.E.F., S.S., J.D.T., D.H.), Department of Anesthesiology and Pain Medicine (D.T., J.D.T.), Section of Pulmonary Medicine (D.H.), Nationwide Children's Hospital, Columbus, OH.
Don
D
Hayes
D000293:Adolescent; D000328:Adult; D005260:Female; D054625:Healthcare Disparities / Q000191:economics / Q000639:trends*; D016027:Heart Transplantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D019458:Insurance Coverage / Q000191:economics / Q000639:trends*; D007348:Insurance, Health / Q000191:economics / Q000639:trends*; D053208:Kaplan-Meier Estimate; D008134:Long-Term Care / Q000191:economics / Q000639:trends*; D008297:Male; D008484:Medicaid / Q000191:economics / Q000639:trends*; D006278:Medicare / Q000191:economics / Q000639:trends*; D008875:Middle Aged; D017149:Private Sector / Q000191:economics / Q000639:trends*; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D017741:Survivors; D013997:Time Factors; D009927:Tissue and Organ Procurement; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
heart transplantation; human; insurance; survival; transplantation