Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance | Gastroenterology | JAMA Network Open | JAMA Network
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    1 Comment for this article
    Disparities in health care
    Frederick Rivara, MD, MPH | University of Washington
    This paper raises some important concerns about potential disparities in health care based on the type of insurance patients who are candidates for liver transplant have. In this time of increasing disparities and appropriate attention to them, the causes for these disparities need to be determined and addressed.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    Gastroenterology and Hepatology
    August 30, 2019

    Comparison of Liver Transplant Wait-List Outcomes Among Patients With Hepatocellular Carcinoma With Public vs Private Medical Insurance

    Author Affiliations
    • 1Department of Medicine, University of California, San Francisco
    • 2Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
    • 3Division of Gastroenterology, Department of Medicine, University of California, San Francisco
    JAMA Netw Open. 2019;2(8):e1910326. doi:10.1001/jamanetworkopen.2019.10326
    Key Points español 中文 (chinese)

    Question  Is type of insurance associated with liver transplant wait-list outcomes among patients with hepatocellular carcinoma?

    Findings  In this cohort study including 705 adult patients with hepatocellular carcinoma Model for End-Stage Liver Disease score exceptions at a single site initially wait-listed for liver transplant, 46.7% of patients with public medical insurance dropped out from the liver transplant wait-list compared with 28.7% of patients with Kaiser Permanente insurance and 33.8% of patients with other private medical insurance despite similar tumor-related characteristics.

    Meaning  Public insurance was associated with increased risk of waiting list dropout, and steps should be implemented to mitigate the increased risk of dropout among these patients.


    Importance  There are well-documented racial/ethnic and socioeconomic disparities in access to health care among patients with hepatocellular carcinoma (HCC); however, there are little data on the association of insurance type with liver transplant (LT) wait-list outcomes for patients with HCC.

    Objective  To examine LT wait-list outcomes for patients with HCC and public insurance compared with patients with private insurance.

    Design, Setting, and Participants  This single-center cohort study included 705 adult patients with HCC who had Model for End-Stage Liver Disease exceptions and were included on a waiting list for LT from January 1, 2010, to December 31, 2016. Patients with Kaiser Permanente medical insurance, other private medical insurance, or public medical insurance were included. Data analysis was conducted from May 2018 to October 2018.

    Main Outcomes and Measures  The main outcome was cumulative incidence of LT waiting list dropout within 2 years of waiting list enrollment (baseline). Secondary outcomes included competing-risks analysis to identify risk factors associated with wait-list outcomes.

    Results  Among 705 patients (median [interquartile range] age, 61 [57-65] years; 537 [76.2%] men) with HCC on an LT waiting list, 349 patients (49.5%) had Kaiser Permanente insurance, 157 patients (22.3%) had other private insurance, and 199 patients (28.2%) had public insurance. Median (interquartile range) follow-up was 13.2 (7.8-18.7) months. Tumor characteristics were similar among insurance types. The cumulative incidence of dropout owing to tumor progression or death within 2 years of baseline was 21.8% (95% CI, 17.2%-26.7%) among the Kaiser Permanente insurance group, 25.5% (95% CI, 18.6%-33.0%) among the other private insurance group, and 35.5% (95% CI, 28.3%-42.7%) among the public insurance group (P < .001). The cumulative incidence of LT within 2 years of baseline was 67.3% (95% CI, 61.2%-72.6%) among the Kaiser Permanente insurance group, 64.1% (95% CI, 55.2%-71.7%) among the other private insurance group, and 48.5% (95% CI, 40.4%-56.1%) among the public insurance group (P < .001). In competing-risks multivariable analysis compared with patients with Kaiser Permanente insurance, patients with public insurance were associated with increased risk of dropout (hazard ratio [HR], 1.69 [95% CI, 1.17-2.43]; P = .005), but patients with other private insurance were not (HR, 1.40 [95% CI, 0.94-2.08]; P = .10). Waiting list dropout was also significantly associated with an α-fetoprotein level 100 ng/mL or higher (HR, 2.8 [95% CI, 1.98-3.88]; P < .001), Model for End-Stage Liver Disease score at baseline (HR per point, 1.06 [95% CI, 1.03-1.09]; P < .001), and 3 or more lesions at baseline (HR vs 1 lesion of 2- to 3-cm diameter, 2.07 [95% CI, 1.27-3.37]; P = .004).

    Conclusions and Relevance  In this large cohort of patients with HCC on an LT waiting list, patients with public insurance were associated with worse wait-list outcomes compared with patients with Kaiser Permanente insurance or other private insurance, despite similar tumor-related characteristics at baseline. Improved health care coordination and delivery may be options to reduce these disparities.