Abstract 16833: Trends in Primary Payer Status and Association With Outcomes in Pediatric Heart Transplantation

Abstract

Background: Pediatric heart transplantation (HT) is resource-intensive. Adult studies have shown an increase in the proportion of adult HT funded by public insurance with outcomes inferior to those with private coverage. Trends in the funding of pediatric HT and associations with outcomes in children have not been described. Methods: We queried the United Network for Organ Sharing (UNOS) database for patients less than 18 years of age, listed for and undergoing HT from 1994 to 2018. We identified primary payer at listing (TCR), transplant (TRR), 1 year follow up, and between 1-5 years following HT. Trends in primary payer were analyzed using generalized logit regression. Cox regression was used to evaluate the impact of insurance on survival. Results: An increase in the proportion of patients with public insurance at the time of HT was observed. Forty eight percent of HT patients in 1994 and 59% in 2018 were publicly insured (P<0.0001). Eight percent of patients changed from private to public insurance between TCR and TRR, and 15% transitioned from private to public from TRR to 1 year post-HT. Of those who changed insurance at one year follow up, 57% transitioned from private to public insurance. For patients undergoing HT, unadjusted long-term survival was worse for patients with public insurance (P <0.0001). When adjusted for age and region, black race (HR 1.57, P <0.001) and age 13-17y (HR 1.44, P<0.0001) were independently associated with mortality. When evaluating outcomes based on change of insurance and adjusting for age and region, age 13-17y (ref <1y, HR 2.3 P <0.0001), white race (ref. black race, HR 0.54, P <0.0001), continuous public insurance (ref continuous private insurance, HR 1.49, P <0.0001), and transition to public insurance (ref continuous private insurance, HR 1.37, P<0.007) were associated with increased mortality. Conclusion: There has been a statistically significant trend towards increasing public insurance for patients awaiting, at the time of, and after HT. Patients that maintain or transition to public insurance following transplant have worse long term outcomes. As the number of patients undergoing HT with public insurance funding continues to increase, understanding of how insurance status impacts long-term outcomes is important.