Dataset Information

Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes.

ABSTRACT:

Background

Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between sex, race/ethnicity, insurance coverage, and neighborhood income and access to/outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did versus did not expand Medicaid.

Methods and results

Retrospective cohort study using State Inpatient Databases to identify patients 18 to 85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012 to 2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925 770 patients were included; 3972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted odds ratio [aOR], 0.45 [0.41-0.49]), black patients (aOR, 0.83 [0.74-0.92]), and Hispanic patients (aOR, 0.74 [0.64-0.87]) were less likely to receive LVADs than whites. Medicare (aOR, 0.79 [0.72-0.86]), Medicaid (aOR, 0.52 [0.46-0.58]), and uninsured patients (aOR, 0.17 [0.11-0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher income areas (aOR, 0.71 [0.65-0.77]). Among those who received LVADs, women (aOR, 1.78 [1.38-2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR, 1.97 [1.42-2.74]), and uninsured patients (aOR, 4.86 [1.92-12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation.

Conclusions

There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.

SUBMITTER: Wang X

PROVIDER: S-EPMC8627192 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:AimsThis study investigated outcomes after continuous flow left ventricular assist device (CF-LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race.Methods and resultsDe-identified data from the United Network for Organ Sharing database was obtained for all patients who had a CF-LVAD as BTT from 2008 to 2018. Patients were stratified into four groups on the basis of ethnicity [Caucasian, African American (AA), Hispanic, and others (Asian, Pacific Islanders, and American Indian)]. Outcomes investigated were waitlist mortality or delisting and post-transplant 5 year survival. Cox proportional hazards modelling was used to identify independent predictors of waitlist mortality or delisting and post-transplant survival. We used Kaplan-Meier survival curves and the log-rank test to estimate and compare survival among groups. A total of 14 234 patients who had CF-LVADs as BTT were identified. Of these, 64% (n = 9058) were Caucasians, 26% (n = 3677) were AA, 7% (n = 997) were Hispanic, and 3% (n = 502) had a different race. Compared with Caucasian, AA, and Hispanic patients had higher body mass indexes and a lower level of education and are more likely to be public health insurance beneficiaries. There was a significantly lower incidence of transplantation in AAs compared with Caucasians, Hispanics, and others at 12, 24, and 60 months, respectively (Gray's test, P < 0.001). The AA race was a significant predictor of waitlist mortality or delisting owing to worsening clinical status [hazard ratio, 95% confidence interval: 1.10 (1.01 to 1.16; P < 0.001)]. Among those who were successfully BTT, risk-adjusted post-transplant survival was similar among the four groups (log-rank test: P = 0.589).ConclusionsDisparities exist among different races that receive a CF-LVAD as a BTT. These disparities translate into increased waitlist morbidity and mortality but not long-term post-transplant survival among those who successfully reach transplant.

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