title: Impact of insurance status on heart transplant wait-list mortality for patients with left ventricular assist devices.
abstract: To test the hypotheses that receipt of Medicaid or Medicare (versus private insurance or self-pay) and low socioeconomic status (SES) leads to increased mortality and lower chances of transplantation among heart transplant (HTx) candidates with bridge to transplant left ventricular assist devices (BTT LVADs).
  
  
  
  Survival while awaiting HTx has improved with the use of BTT LVADs. However, it is unknown whether benefits extend uniformly across patient groups based on insurance status.
  
  
  
  Data from the United Network of Organ Sharing (UNOS) registry between 2006 and 2015 were examined for first-time HTx candidates ≥18 and <65 years who had LVAD support while wait-listed. Multivariable survival analysis was conducted on competing outcomes of mortality and time to transplant stratified by insurance source at the time of listing. Additional covariates included demographic information and SES.
  
  
  
  A total of 4626 patients met inclusion criteria, with 3353 being used for multivariable analysis. A majority of patients (68%) underwent HTx during the study period. BTT LVAD wait-list mortality was found to be greater among Medicaid beneficiaries vs. private insurance (SHR 1.57, P<.05) and did not diminish with the inclusion of neighborhood SES. Transplantation as an outcome demonstrated no difference by insurance status.
  
  
  
  Medicaid insurance status is associated with worse survival on the HTx wait-list among patients with BTT LVADs, although access to transplant was not different among insurance groups. The disparity is not reflective of SES in general and therefore points to other barriers inherent to Medicaid beneficiaries.
authors.affiliation: Department of Internal Medicine (Division of Cardiology), The Ohio State University College of Medicine, Columbus, OH, USA.|Center for the Epidemiological Study of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Sitaramesh
authors.initials: S
authors.lastname: Emani
authors.affiliation: Center for the Epidemiological Study of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.|Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Dmitry
authors.initials: D
authors.lastname: Tumin
authors.affiliation: Department of Internal Medicine (Division of Cardiology), The Ohio State University College of Medicine, Columbus, OH, USA.|Center for the Epidemiological Study of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH, USA.|Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH, USA.
authors.forename: Randi E
authors.initials: RE
authors.lastname: Foraker
authors.affiliation: Department of Internal Medicine (Division of Cardiology), The Ohio State University College of Medicine, Columbus, OH, USA.|Center for the Epidemiological Study of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.|Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.|Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Don
authors.initials: D
authors.lastname: Hayes
authors.affiliation: Department of Internal Medicine (Division of Cardiology), The Ohio State University College of Medicine, Columbus, OH, USA.|Center for the Epidemiological Study of Organ Failure and Transplantation, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Sakima A
authors.initials: SA
authors.lastname: Smith
mesh_terms: D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000628:therapy*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012042:Registries; D015996:Survival Rate; D013997:Time Factors; D014481:United States; D014850:Waiting Lists / Q000401:mortality*
keywords: Medicaid; bridge to transplant; left ventricular assist device; wait-list