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Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance

IMPORTANCE: There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. OBJE...

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Autores principales: Gutin, Liat, Yao, Francis, Dodge, Jennifer L., Grab, Joshua, Mehta, Neil
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724163/
https://www.ncbi.nlm.nih.gov/pubmed/31469395
http://dx.doi.org/10.1001/jamanetworkopen.2019.10326
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author Gutin, Liat
Yao, Francis
Dodge, Jennifer L.
Grab, Joshua
Mehta, Neil
author_facet Gutin, Liat
Yao, Francis
Dodge, Jennifer L.
Grab, Joshua
Mehta, Neil
author_sort Gutin, Liat
collection PubMed
description IMPORTANCE: There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. OBJECTIVE: To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. DESIGN, SETTING, AND PARTICIPANTS: This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. MAIN OUTCOMES AND MEASURES: The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. RESULTS: Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). CONCLUSIONS AND RELEVANCE: In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.
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spelling pubmed-67241632019-09-17 Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance Gutin, Liat Yao, Francis Dodge, Jennifer L. Grab, Joshua Mehta, Neil JAMA Netw Open Original Investigation IMPORTANCE: There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC. OBJECTIVE: To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. DESIGN, SETTING, AND PARTICIPANTS: This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018. MAIN OUTCOMES AND MEASURES: The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes. RESULTS: Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004). CONCLUSIONS AND RELEVANCE: In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities. American Medical Association 2019-08-30 /pmc/articles/PMC6724163/ /pubmed/31469395 http://dx.doi.org/10.1001/jamanetworkopen.2019.10326 Text en Copyright 2019 Gutin L et al. JAMA Network Open. http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Original Investigation
Gutin, Liat
Yao, Francis
Dodge, Jennifer L.
Grab, Joshua
Mehta, Neil
Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
title Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
title_full Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
title_fullStr Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
title_full_unstemmed Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
title_short Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance
title_sort comparison of liver transplant wait-list outcomes among patients with hepatocellular carcinoma with public vs private medical insurance
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6724163/
https://www.ncbi.nlm.nih.gov/pubmed/31469395
http://dx.doi.org/10.1001/jamanetworkopen.2019.10326
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