Disparities in Socioeconomic Status and Access to Lung Transplantation in Cystic Fibrosis

Abstract

Context: Patients with Medicaid experience persistent health disparities for a wide range of diseases and treatments in the United States compared to those without Medicaid, but disparities with respect to access to lung transplantation for cystic fibrosis (CF) patients are largely unknown. Objective: To determine whether access to lung transplantation for CF patients with end-stage lung disease differs according to Medicaid status. Design, Setting and Participants: Observational study of 2,167 adult CF patients with end-stage lung disease who underwent initial lung transplant evaluation between 2001 to 2009 identified through the United States CF Foundation Patient Registry including 1009 (47%) receiving Medicaid and 1158 (53%) without Medicaid. The main outcome measure was acceptance for lung transplant following evaluation. Results: 1,349 (62%) of 2,167 adult CF patients who underwent lung transplant evaluation were accepted. In a multivariate logistic model accounting for demographic characteristics, disease severity, potential contraindications to lung transplant, and pre-/post-use of the lung allocation score, Medicaid recipients were 54% [95% confidence interval (CI):25%-88%] more likely to be not accepted for lung transplant compared to patients without Medicaid. This association was independent of other SES indicators including race, education, zip code median household income, and driving time from residence to closest transplant center (OR=1.37, 95% CI:1.10-1.72). Patients not completing high school (OR=2.37, 95% CI:1.49-3.79) and those residing in the lowest (vs. highest) zip code median household income category (OR=1.39, 95% CI:1.01-1.93) were also more likely not to be accepted for lung transplant. Conclusions: In this nationally representative study of adult CF patients, multiple indicators of a lower socioeconomic position, including receipt of Medicaid, were associated with higher likelihoods of not being accepted for lung transplant. A more complete understanding of what specific aspects of socioeconomic position influence acceptance for lung transplantation is needed in order to ensure more equitable allocation of this treatment.