Association of Primary Payer Status and In-Hospital Mortality among Liver Transplant Recipients: A National Perspective

Abstract

Purpose: As the efficacy of health insurance comes into question, the debate regarding healthcare reforms of the primary payer status continues in the United States. While outcomes following liver transplantation have been consistently improving over the past several years, little is known about whether the primary payer status has any role in outcomes among liver transplant patients. Methods: We used the 2010 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) to evaluate patients who obtained a liver transplant (ICD 9 procedure codes 50.5). Sample weights were developed to enable nationwide estimates. Patients were stratified by primary payer statuses: Medicare, Medicaid, uninsured, and private insurance. Multivariable logistic regression models were used to assess the effect of primary payer status on in-hospital mortality. Results: Of a total of ˜40 million nationwide hospitalizations, 5,971 had undergone liver transplant. Liver transplant patients had a mean age of 50 (±17) years, 35% were women, and 34% were non-whites. Medicare, Medicaid, uninsured, and private insurance payer status were associated with an in-hospital mortality rate of 3.6%, 7.0%, 12.2%, and 3.4%, respectively. Length of stay was longest for Medicaid patients (28.5 ± 39.8 days) and shortest for private insurance patients (19.5 ± 21.9 days, P<0.001). After controlling for patient risk factors, hospital features, and operative volume, Medicaid (odds ratio [OR] 2.20; 95% confidence interval [CI] 1.54-3.14; P<0.001) and uninsured (OR 6.89; 95% CI 2.50-18.98; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality (Table).Table: Table: Primary payer status and in-hospital mortality among liver transplant patientsConclusion: Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing liver transplants. Delays in access to care or health maintenance disparities could be possible explanations. With the advent of health care reform, this may mandate a closer look into the current resource utilization strategies to reduce such disparities among the liver transplant patients.