Increased Mortality in Adult Cystic Fibrosis Patients with Medicaid Insurance Awaiting Lung Transplantation.

PURPOSE: Cystic fibrosis (CF) is a progressive disease resulting in end-stage lung disease. Lung transplantation (LTx) is an important consideration in these patients. Studies have suggested greater post-LTx mortality among CF patients with public insurance. We evaluated the influence of insurance status on survival among CF patients during their time on the LTx waitlist. METHODS: Adult LTx candidates diagnosed with CF and listed since the implementation of the lung allocation score, from May 2005 until September 2013, were identified in the United Network for Organ Sharing database. Waitlist mortality was compared across projected primary payment type (private insurance or self-pay; Medicaid; Medicare) using Kaplan-Meier functions and Fine-Gray competing-risks survival analysis, accounting for the competing risk of transplantation. RESULTS: 1770 LTx candidates with CF were included in univariate survival analyses, with Medicaid increasing waitlist mortality hazard relative to private insurance (HR 2.28; 95 % CI 1.62, 3.21; p < 0.001) and relative to Medicare (HR 2.23; 95 % CI 1.43, 3.48; p < 0.001). A multivariable competing-risks model confirmed greater waitlist mortality among Medicaid patients relative to private insurance (HR 2.57; 95 % CI 1.56, 4.23; p < 0.001) or patients with Medicare (HR 4.02; 95 % CI 1.98, 8.17; p < 0.001) after adjusting for potential confounders. No differences in waitlist survival were found between Medicare and private insurance. CONCLUSIONS: CF patients with Medicaid insurance have higher risk of death while awaiting LTx when compared to patients with Medicare or private insurance. The impact of insurance status on survival in this population begins before LTx and compounds the disparities previously observed in post-transplant outcomes.