Abstract
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. To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance. 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. 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. 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). 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.
Highlights
Hepatocellular carcinoma (HCC) is an aggressive malignant neoplasm that is the fifth most common cancer worldwide and the third leading cause of cancer-related deaths.[1]
In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout, but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10)
Waiting list dropout was significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.983.88]; 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)
Summary
Hepatocellular carcinoma (HCC) is an aggressive malignant neoplasm that is the fifth most common cancer worldwide and the third leading cause of cancer-related deaths.[1] The incidence of HCC continues to increase in the United States, a recent analysis showed that the rate of increase slowed between 2006 and 2011, likely owing to improved HCC primary prevention strategies, improvements in the treatment of viral hepatitis, and increased use of curative modalities.[2] The only curative therapies for HCC are surgical, including tumor resection, liver transplant (LT), or local ablation.[3,4] Despite these improvements in HCC incidence, there are well-documented socioeconomic and racial disparities in accessing care for patients with HCC. Among US adults with HCC, patients who were uninsured or had Medicaid had more advanced tumor stage at diagnosis, lower rates of tumor-directed treatment, and lower overall survival.[9,10,11,12] As more patients are using public insurance to cover the cost of LT since the Patient Protection and Affordable Care Act Medicaid expansion policy came into effect in 2014,13,14 these disparities are becoming increasingly concerning
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