Advertisement
The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Impact of race and health coverage on listing and waitlist mortality in pediatric cardiac transplantation

Published:December 07, 2022DOI:https://doi.org/10.1016/j.healun.2022.12.002

      Background

      Social factors like race and insurance affect transplant outcomes. However, little is known in pediatric heart transplantation. We hypothesized that race and insurance coverage impact listing and waitlist outcomes across eras.

      Methods

      Data from the Pediatric Heart Transplant Society multi-center registry prospectively collected between January 1, 2000-December 31, 2019 were analyzed. Patients were divided by race as Black, White and other and by insurance coverage at listing (US governmental, US private and non-US single payer systems (UK, Canada). Clinical condition at listing and waitlist outcomes were compared across races and insurance coverages. Categorical variables were compared using a chi-square test and continuous variables using the Wilcoxon rank sum test. Risk factors for waitlist mortality were examined using multiphase parametric hazard modeling. A sensitivity analysis using parametric hazard explored the interaction between race and insurance.

      Results

      At listing, compared to Whites (n = 5391) and others (n = 1167), Black patients (n = 1428) were older, more likely on US governmental insurance and had cardiomyopathy as the predominant diagnosis (p < 0.0001). Black patients were more likely to be higher status at listing, in hospital, on inotropes or a ventricular assist device (p < 0.0001). Black patients had significantly shorter time on the waitlist compared to other races (p < 0.0001) but had higher waitlist mortality (p = 0.0091), driven by the earlier era (2000-2009) (p = 0.0005), most prominently within the US private insurance cohort (p = 0.015). Outcomes were not different in other insurance cohorts or in the recent era (2010-2019).

      Conclusion

      Black children are older and sicker at the time of listing, deteriorate more often and face a higher wait list mortality, despite a shorter waitlist period and favorable clinical factors, with improvement in the recent era associated with the recent US healthcare reforms. The social construct of race appears to disadvantage Black children by limiting referral, consideration or access to pediatric cardiac transplantation.

      KEYWORDS

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Heart and Lung Transplantation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Chouairi F
        • Fuery M
        • Clark KA
        • et al.
        Evaluation of racial and ethnic disparities in cardiac transplantation.
        J Am Heart Assoc. 2021; 10e021067
        • Liu V
        • Bhattacharya J
        • Weill D
        • Hlatky MA.
        Persistent racial disparities in survival after heart transplantation.
        Circulation. 2011; 123: 1642-1649
        • Amdani S
        • Bhimani SA
        • Boyle G
        • et al.
        Racial and ethnic disparities persist in the current era of pediatric heart transplantation.
        J Card Fail. 2021; 27: 957-964
        • Kocher R
        • Emanuel EJ
        • DeParle NA.
        The Affordable Care Act and the future of clinical medicine: the opportunities and challenges.
        Ann Intern Med. 2010; 153: 536-539
        • Blackstone EH
        • Naftel DC
        • Turner ME.
        The decomposition of time-varying hazard into phases, each incorporating a separate stream of concomitant information.
        J Am Statist Assoc. 1986; 81: 615-624
        • Singh TP
        • Almond CS
        • DO Taylor
        • Milliren CE
        • Graham DA.
        Racial and ethnic differences in wait-list outcomes in patients listed for heart transplantation in the United States.
        Circulation. 2012; 125: 3022-3030
        • Jeewa A
        • Manlhiot C
        • Kantor PF
        • Mital S
        • McCrindle BW
        • Dipchand AI.
        Risk factors for mortality or delisting of patients from the pediatric heart transplant waiting list.
        J Thorac Cardiovasc Surg. 2014; 147: 462-468
        • Lewsey SC
        • Breathett K.
        Equity in heart transplant allocation: intended progress up the hill or an impossibility?.
        J Am Heart Assoc. 2021; 10e022817
        • Carlo WF
        • Floyd S
        • Pearce FB
        • et al.
        Examining racial and socioeconomic disparity in the pediatric heart transplant evaluation.
        Pediatr Transplant. 2021; 25: e13979
        • Higgins RS
        • Fishman JA.
        Disparities in solid organ transplantation for ethnic minorities: facts and solutions.
        Am J Transplant. 2006; 6: 2556-2562
        • Breathett K
        • Yee E
        • Pool N
        • et al.
        Does race influence decision making for advanced heart failure therapies?.
        J Am Heart Assoc. 2019; 8e013592
        • Groman R
        • Ginsburg J.
        Racial and ethnic disparities in health care: a position paper of the American College of Physicians.
        Ann Intern Med. 2004; 141: 226-232
        • Wadhwani SI
        • Ge J
        • Gottlieb L
        • et al.
        Racial/Ethnic disparities in wait list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation.
        Hepatology (Baltimore, Md). 2022; 75: 115-124
        • Sohn H.
        Racial and ethnic disparities in health insurance coverage: dynamics of gaining and losing coverage over the life-course.
        Popul Res Policy Rev. 2017; 36: 181-201
        • Pagani FD.
        Insurance coverage and heart transplant outcomes.
        Circ Cardiovasc Qual Outcomes. 2016; 9: 501-503
        • Wray CM
        • Khare M
        • Keyhani S.
        Access to care, cost of care, and satisfaction with care among adults with private and public health insurance in the US.
        JAMA Netw Open. 2021; 4e2110275
        • Oliveira GH
        • Al-Kindi SG
        • Simon DI.
        Implementation of the affordable care act and solid-organ transplantation listings in the United States.
        JAMA Cardiol. 2016; 1: 737-738
      1. Center KCD. Child population by race in the United States: United States Census Bureau; 2020. Available at: https://datacenter.kidscount.org/. Accessed April 20, 2022.

        • Kilic A
        • Higgins RS
        • Whitson BA
        • Kilic A.
        Racial disparities in outcomes of adult heart transplantation.
        Circulation. 2015; 131: 882-889
        • Bakhtiyar SS
        • Godfrey EL
        • Ahmed S
        • et al.
        Survival on the heart transplant waiting list.
        JAMA Cardiol. 2020; 5: 1227-1235