Medicaid Status May Worsen Complications After Heart Transplantation

Medicaid-insured heart transplant recipients exhibited an amplified risk of developing cardiac allograft vasculopathy (CAV) over 5 years, according to a new analysis of the link between socioeconomic status and post-transplant complications.1

Among more than 37,000 adults who received a heart transplant, those with Medicaid insurance experienced worse survival rates in that period, particularly those in the post-Affordable Care Act (ACA) era (2014-2022). These data were presented in a plenary session at the 61st Annual Meeting of the Society of Thoracic Surgeons (STS).

“CAV is a leading cause of morbidity and mortality following heart transplant. Our work demonstrates that socioeconomic disadvantage influences the risk of CAV in the months and years following this life-saving operation,” investigator Sara Sakowitz, MPH, a medical student at the David Geffen School of Medicine at UCLA, said in a statement.2

CAV can severely impact transplanted hearts and limited long-term survival, with evidence linking CAV to more than 30% of all deaths in the first 5 to 10 years after heart transplantation.3 Patient factors, including socioeconomic disadvantage and insurance status, contribute to inferior post-transplant survival rates, but the exact mechanisms are unknown, according to Sakowitz and colleagues.1

The team identified heart transplant recipients aged ≥18 in the 2004-2022 Organ Proceurement and Transplantation Network for this analysis, defining CAV as evidence of any angiographic coronary disease. Patients were stratified by insurance status into Medicaid and non-Medicaid cohorts and the study period into pre-ACA (2004-2013) and post-ACA era (2014–2022).

Institutional volume was considered in the analysis, deeming hospitals with ≥19 cases per year in the highest quartile as “High-Volume Centers.” Among a population of 37,073 identified heart transplant recipients, the analysis showed 4875 (13%) were insured by Medicaid.

Overall, Sakowitz and colleagues found the incidence of CAV was 31%. After performing risk adjustment, they found Medicaid insurance showed a significantly greater likelihood of CAV development over 5 years (hazard ratio [HR], 1.08; 95% CI, 1.01–1.16). They noted the impact greater in the post-ACA era (HR, 1.11; 95% CI, 1.02–1.21), compared with the pre-ACA era (HR, 1.07; 95% CI, 0.84–1.36).

“Although the ACA has expanded access to heart transplantation for previously uninsured patients, significant barriers to accessing longitudinal post-transplant treatment, unaffordable medications, and equitable, high-quality care remain,” Sakowitz added.2

For those patients at high-volume institutions (≥19 cases per year), Medicaid insurance demonstrated a comparable likelihood of CAV (HR, 1.04; 95% CI, 0.95–1.14) as non-Medicaid insurance. However, when considering patients at non-high-volume centers, Medicaid was linked to significantly greater CAV risk (HR, 1.14; 95% CI, 1.03–1.26).1

Overall, the analysis correlated Medicaid insurance status with worse patient (HR, 1.31; 95% CI, 1.21–1.42) and allograft survival outcomes at the 5-year mark (HR, 1.29; 95% CI, 1.19–1.39).1 Sakowitz and colleagues indicated factors at high-volume transplant centers, including comprehensive care teams and streamlined protocols, could influence these superior outcomes, calling for further investigation into outcomes for vulnerable populations post-transplantation.

“Patients treated at high-volume transplant centers often benefit from specialized expertise, comprehensive care, and robust patient support systems,” investigator Peyman Benharash, MD, a cardiothoracic surgeon at UCLA Health, said in a statement.2 “These centers are equipped with dedicated teams and streamlined protocols that ensure consistent follow-up and access to essential medications, significantly improving post-transplant outcomes and survival rates.”

References

1. Sakowitz S, Bakhtiyar SS, Mallick S, Higgins R, Shemin R, Benharash P. Insurance-Based Disparities in Cardiac Allograft Vasculopathy Following Heart Transplantation Are Mediated by Care at High Volume Centers. The Annals of Thoracic Surgery. January 24, 2025. Accessed January 24, 2025. https://www.annalsthoracicsurgery.org/article/S0003-4975(25)00072-4/fulltext.
2. Medicaid-insured heart transplant patients face higher risk of post-transplant complications. UCLA Health. January 24, 2025. Accessed January 24, 2025. https://www.uclahealth.org/news/release/medicaid-insured-heart-transplant-patients-face-higher-risk.
3. Agarwal S, Parashar A, Kapadia SR, et al. Long-term mortality after cardiac allograft vasculopathy: implications of percutaneous intervention. JACC Heart Fail. 2014;2(3):281-288. doi:10.1016/j.jchf.2014.01.003