Discrepancies in survival following pediatric heart transplantation and the effect of race and socioeconomic status on outcomes

Abstract

Objectives

Poor health literacy and resources paucity in families with low socioeconomic status can be detrimental in children requiring complex outpatient management such as heart transplantation. We assessed the influence of socioeconomic status and insurance type on heart transplantation outcomes.

Methods

The cohort of children undergoing heart transplantation was generated by merging the United Network for Organ Sharing and Pediatric Health Information System databases. Family's annual income was used as surrogate for socioeconomic status. Children were divided into 3 groups: low-income (lower quartile, <$32 700; n = 639), medium-income (second and third quartiles, $32 700-$53 600; n = 1305), or high-income (upper quartile, >$53 600; n = 649).

Results

Comparison showed racial discrepancies (more Whites in high-income, more Blacks in low-income groups), and insurance type variations (more private in high-income, more Medicaid in low-income groups). On univariate analysis, survival was higher for high-income compared with medium-income and low-income groups (P = .04). On multivariable analysis, Black race (hazard ratio, 1.389; 95% CI, 1.041-1.703; P = .0075), Medicaid (hazard ratio, 1.373; 95% CI, 1.115-1.721; P = .0038), and other government insurance (hazard ratio, 1.611; 95% CI, 1.104-2.423; P = .0126) were significant risk factors, whereas income group effect was neutralized. Treated rejection episodes at 1 year were lowest (10%) in high-income and highest (15%) in low-income groups, with trend for less rejection in the low-income group with private insurance (12% vs 16%). Death from cardiac arrest was significantly less in the high-income (8%) compared with the medium-income (18%) and low-income (19%) groups (P < .01).

Conclusions

Black and low socioeconomic status children face significant disadvantages in heart transplant outcomes, including lower survival, higher rejection rates, and increased risk of death secondary to cardiac arrest. Access to private insurance leads to better survival but might be proxy to better resources, education, and compliance.