Impact of Insurance Status on Pediatric Heart Transplant Recipients

Abstract

Gaps in insurance coverage and change in coverage type have been strongly associated with diminished access to health care for children. Continuity of insurance coverage is associated with improved long-term clinical outcomes among adolescent heart transplant (HT) recipients, but the relationship between insurance status and post-transplant outcomes has not been described across all pediatric HT recipients. We queried the United Network for Organ Sharing (UNOS) registry for patients age 0-17 years listed for isolated HT or heart re-transplant between July 2006 and March 2019 and included them in the analysis if they survived at least one year post-transplant. Patients were categorized by insurance coverage at transplantation and at one year follow-up. Cox proportional hazards models were used to characterize the association between coverage pattern and transplant survival conditional upon survival to one year. Among the 3,260 patients in the analysis, insurance coverage patterns included continuous private insurance (39%), continuous public insurance (49%), loss of private insurance (8%), and gain of private insurance (4%). Patients who had public insurance or a change in insurance status were more likely to be Black, but did not otherwise differ from other patients by indication for HT, LVAD use, or medical condition at the time of transplant. In a multivariable Cox model, when compared with continuous private insurance, continuous public insurance (HR 1.42; 95% CI: 1.13-1.77; P = 0.02) and loss of private insurance (HR 1.23; 95% CI 0.83-1.82) were associated with greater mortality hazard. Kaplan-Meier conditional survival curves according to insurance trajectory are illustrated in Figure 1. Public insurance at HT and 1 year post-HT is associated with reduced 1-year conditional survival compared to private insurance. There is a trend toward reduced 1-year conditional survival among patients who lose private insurance by 1 year post-HT.