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Temporal trends in primary payers in pediatric heart transplant and association with long-term survival
Kathryn Restaino1, Xuemei Zhang2, Jennifer A Faerber2
1Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Insights
Public insurance is increasingly common for pediatric heart transplants (HT), but it is linked to worse long-term outcomes. This trend highlights disparities in pediatric HT, necessitating efforts to ensure equitable results for all children undergoing this procedure.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Health Services Research
Background:
- Pediatric heart transplantation (HT) is a complex and resource-intensive procedure.
- In adults, a rise in public insurance for HT correlates with poorer outcomes compared to private insurance.
- Data on funding trends and outcomes for pediatric HT are lacking.
Purpose of the Study:
- To describe trends in insurance coverage for pediatric heart transplantation.
- To evaluate the association between insurance type and post-transplant outcomes in children.
Main Methods:
- Utilized the United Network for Organ Sharing (UNOS) database for pediatric patients (<18 years) from 2004-2021.
- Analyzed primary payer at listing, transplant, and 1-5 years post-transplant.
- Employed generalized logit models for trend analysis and multivariable Cox regression for outcome analysis.
Main Results:
- Over 6382 pediatric patients were included, with a growing proportion having public insurance at the time of HT.
- Public insurance at HT was associated with a significantly increased risk of death or re-transplant beyond 2 months post-transplant (e.g., adjusted HR of 1.43 at 6 months).
Conclusions:
- A significant trend towards increased public insurance coverage in pediatric HT recipients exists.
- Worse long-term outcomes are observed in Black patients and those with public insurance at the time of HT.
- These findings underscore disparities in pediatric HT and the critical need for equitable outcomes.
Background:
Pediatric heart transplantation (HT) is resource intensive. In adults, there has been an increase in the proportion of HTs funded by public insurance, with post-HT outcomes inferior to those funded by private sources. Trends in the funding of pediatric HT and outcomes in children have not been described.
Methods:
We queried the United Network for Organ Sharing (UNOS) database for children (<18 years) listed for and undergoing HT between 2004 and 2021. We identified the primary payer at listing, HT, 1 year, and 1-5 years following HT. Trends were analyzed using generalized logit models. Multivariable-extended Cox regression models were used to test the relationship between insurance type at the time of transplant and time to death or re-transplant.
Results:
There were 6382 pediatric patients who underwent transplants and had either public or private insurance at the time of transplant. The percentage of patients with public insurance at the time of HT increased over time. Public insurance at the time of HT was associated with an increased risk of death or re-transplant beyond 2 months after HT (adjusted HR at 6 months = 1.43, 95% CI: 1.13-1.81, p = .003; adjusted HR at 9 months = 1.67, 95% CI: 1.17-2.37, p = .004).
Conclusion:
There has been a statistically significant trend toward increasing public insurance for children awaiting, at the time of, and after HT. Black patients and those with public insurance at HT have worse long-term outcomes. This study highlights ongoing disparities in pediatric HT and the need to focus efforts on achieving equitable outcomes.
