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Public insurance a risk factor for worse liver transplant waitlist outcomes

Patients with hepatocellular carcinoma on a liver transplantation waitlist who had public insurance had worse waitlist outcomes compared with those who had Kaiser Permanente or other private insurance, according to data published in JAMA Network Open.

“Our study found that, despite similar tumor- and liver disease-related characteristics at the time of listing with an HCC MELD exception, patients with public insurance were the least likely to undergo LT and had the highest rate of waiting list dropout compared with patients with Kaiser Permanente or other private insurance,” Liat Gutin, MD, from the University of California in San Francisco, and colleagues wrote.

The study comprised 349 patients with Kaiser Permanente insurance, 157 patients with other private insurance, and 199 patients with public insurance. During follow-up, 246 patients dropped from the LT waitlist for any reason during the study, including 174 who dropped from the waitlist due to tumor progression or mortality.

At 2 years, the cumulative incidence of dropout was lowest among patients with Kaiser Permanente insurance (21.8%; 95% CI, 17.2-26.7), followed by those with other private insurance (25.5%; 95% CI, 18.6-33), and highest among those with public insurance (35.5%; 95% CI, 28.3-42.7).

Similarly, more patients with Kaiser Permanente (67.3%; 95% CI, 61.3-72.6) or other private insurance (64.1%; 95% CI, 55.2-71.7) underwent LT with a deceased donor organ compared with patients with public insurance (48.5%; 95% CI, 40.4-56.1).

Multivariate analysis confirmed that the risk for dropout was increased for patients with public insurance compared with those with Kaiser Permanente insurance (HR = 1.69; 95% CI, 1.17-2.43).

Additionally, waitlist dropout correlated with alpha-fetoprotein levels of 100 ng/mL or higher (HR = 2.77; 95% CI, 1.98-3.88), MELD score at baseline (HR per point = 1.06; 95% CI, 1.03-1.09), and three lesions at baseline compared with one lesion with 2 cm to 3 cm diameter (HR = 2.07; 95% CI, 1.27-3.37).

“These findings appear to be associated with delays in completing pre-LT evaluations and obtaining timely MELD exception upgrades,” Gutin and colleagues concluded. “Public insurance should be recognized as a risk factor associated with waiting list dropout, and necessary steps should be implemented to mitigate the increased risk of dropout among these patients.” – by Talitha Bennett

Disclosures: The authors report no relevant financial disclosures.