心脏移植术后基于保险的心脏移植血管病变差异是由高容量中心的护理介导的。

Insurance-Based Disparities in Cardiac Allograft Vasculopathy After Heart Transplantation Are Mediated by Care at High-Volume Centers.

作者信息

Sakowitz Sara, Bakhtiyar Syed Shahyan, Mallick Saad, Pereira Sara, Nelson Jennifer S, Parikh Rushi, Higgins Robert S D, Shemin Richard J, Benharash Peyman

机构信息

Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California.

Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, California; Department of Surgery, University of Colorado, Aurora, Colorado.

出版信息

Ann Thorac Surg. 2025 Jan 24. doi: 10.1016/j.athoracsur.2025.01.008.

DOI:10.1016/j.athoracsur.2025.01.008

PMID:39864773

Abstract

BACKGROUND

Socioeconomic disadvantage and Medicaid insurance have been linked with inferior survival after heart transplantation, yet the contributing mechanisms remain to be elucidated. We evaluated the association of Medicaid with the development of cardiac allograft vasculopathy (CAV).

METHODS

We considered heart transplant recipients aged ≥18 years within the 2004-2022 Organ Procurement and Transplantation Network. CAV was defined as any evidence of angiographic coronary disease. Institutional volume was computed, with hospitals in the highest quartile (≥19 cases/y) categorized as high-volume centers. Patients were stratified by insurance into the Medicaid and Non-Medicaid cohorts. The study period was divided into the pre-Affordable Care Act (ACA; 2004-2013) and post-ACA eras (2014-2022).

RESULTS

Of 37,073 heart transplant recipients, 4875 (13%) were insured by Medicaid. The overall incidence of CAV was 31%. After risk-adjustment, Medicaid insurance was linked with significantly greater likelihood of developing CAV over 5 years (Hazard Ratio [HR], 1.08, 95% CI, 1.01-1.16). Importantly, this effect seems to have emerged in the post-ACA era (Pre-ACA HR, 1.07, 95% CI 0.84-1.36; Post-ACA HR, 1.11, 95% CI, 1.02-1.21). Furthermore, among patients at high-volume centers, Medicaid insurance was linked with similar CAV likelihood (HR, 1.04, 95% CI, 0.95-1.14). Yet, considering those treated at non-high-volume centers, Medicaid was associated with significantly greater CAV hazard (HR, 1.14, 95% CI, 1.03-1.26). Overall, Medicaid remained associated with inferior patient (HR, 1.31, 95% CI, 1.21-1.42) and allograft survival at 5 years (HR, 1.29, 95% CI, 1.19-1.39).

CONCLUSIONS

Medicaid-insured recipients faced inferior survival and greater risk of CAV over 5 years. Our work encourages closer follow-up and treatment for vulnerable populations in the months and years post-transplantation.

摘要

背景

社会经济劣势和医疗补助保险与心脏移植后较差的生存率相关，但其中的作用机制仍有待阐明。我们评估了医疗补助保险与心脏移植血管病变（CAV）发生之间的关联。

方法

我们纳入了2004 - 2022年器官获取与移植网络中年龄≥18岁的心脏移植受者。CAV被定义为血管造影显示的任何冠心病证据。计算机构手术量，手术量处于最高四分位数（≥19例/年）的医院被归类为高手术量中心。患者按保险类型分为医疗补助队列和非医疗补助队列。研究期分为《平价医疗法案》（ACA）实施前（2004 - 2013年）和ACA实施后（2014 - 2022年）两个阶段。

结果

在37,073名心脏移植受者中，4875名（13%）有医疗补助保险。CAV的总体发生率为31%。经过风险调整后，医疗补助保险与5年内发生CAV的可能性显著增加相关（风险比[HR]，1.08，95%置信区间，1.01 - 1.16）。重要的是，这种影响似乎在ACA实施后时代出现（ACA实施前HR，1.07，95%置信区间0.84 - 1.36；ACA实施后HR，1.11，95%置信区间，1.02 - 1.21）。此外，在高手术量中心的患者中，医疗补助保险与CAV发生可能性相似（HR，1.04，95%置信区间，0.95 - 1.14）。然而，对于在非高手术量中心接受治疗的患者，医疗补助保险与显著更高的CAV风险相关（HR，1.14，95%置信区间，1.03 - 1.26）。总体而言，医疗补助保险在5年时仍与较差的患者生存率（HR，1.31，95%置信区间，1.21 - 1.42）和移植物生存率（HR，1.29，95%置信区间，1.19 - 1.39）相关。