Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States.

Although socioeconomic disparities persist both pre- and post-transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States. All adults (age ≥18 years) listed for LT between 2002 and 2018 in the United Network for Organ Sharing database were included. The primary outcome was waitlist removal because of death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal-Wallis and chi-square tests, respectively. Fine and Gray competing-risks regression was used to estimate the subdistribution hazard ratios (HRs) for risk factors associated with delisting. Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare, and 15.9% by Medicaid. The 1-year cumulative incidence of delisting was 9.0% (95% confidence interval [CI], 8.3%-9.8%) for patients with private insurance, 10.7% (95% CI, 9.9%-11.6%) for Medicare, and 10.7% (95% CI, 9.8%-11.6%) for Medicaid. In multivariable competing-risks analysis, Medicare (HR, 1.20; 95% CI, 1.17-1.24; P < 0.001) and Medicaid (HR, 1.20; 95% CI, 1.16-1.24; P < 0.001) were independently associated with an increased hazard of death or deterioration compared with private insurance. Additional predictors of delisting included Black race and Hispanic ethnicity, whereas college education and employment were associated with a decreased hazard of delisting. In this study, LT candidates with Medicare or Medicaid had a 20% increased risk of delisting because of death or clinical deterioration compared with those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population.

Disparities in kidney transplantation across the United States: Does residential segregation play a role?

BACKGROUND: Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. METHODS: Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000-2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. RESULTS: Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. CONCLUSION: Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. SUMMARY: Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.