Liver transplantation for biliary atresia: Does the insurance type really make a difference?

In this issue of Liver Transplantation, Arnon et al. postulate that public health insurance is a marker for poorer outcomes as judged by patient and graft survival after liver transplantation in children with biliary atresia. Not surprisingly, the authors found that children covered by Medicaid, the Children’s Health Insurance Program, or other government-funded insurance [public insurance (PU)] had significantly poorer results than children whose health care was privately insured [private insurance (PR)]. These results are consistent with those of many others who have linked lower socioeconomic status (SES) and poor outcomes of medical care in a variety of clinical settings. To do their study, the authors accessed the Standard Transplant Analysis and Research data set files of the Organ Procurement and Transplantation Network and thus were constrained in the depth of their analysis because of the nature and extent of the data that are collected both before and after transplantation. The authors concluded that PU and, by proxy, lower SES are associated with increased mortality on the pretransplant wait list and decreases in both early and late patient and graft survival. Additionally, deceased donor transplantation and life support at the time of transplantation were also risk factors for lower survival. Although patients with PU were less likely to receive a living donor transplant, this alone was not enough to explain the differences in outcomes observed by the authors, although it may have accounted for the lower waiting period for transplantation experienced by patients in the PR group. This article offers a provocative conclusion but very little in the way of explanation or recommendations that could level the playing field for children with PU. Despite the wealth of data that are analyzed in this article, much of the information that would be needed to arrive at more meaningful conclusions is simply not available in the Standard Transplant Analysis and Research database. The authors offer potential explanations in their discussion, but these are purely speculative and need to be corroborated with more focused and prospective analyses. Although there are data showing that SES and lower levels of education directly affect outcomes after adult transplantation, the authors could not conclude the same for children because of a lack of data concerning important parental and social factors. One of the more reassuring facts that readers can take away from this article is that access to transplantation is not a factor in explaining the poorer results. The times between listing and transplantation, the proportions of patients with high Pediatric End-Stage Liver Disease scores and status 1 listings, and the numbers of exceptions that were submitted and approved were equal for the PU and PR groups. Furthermore, even in the PU group, the results 5 years after transplantation were excellent, with patient survival rates of 92.2% for the PU group and 97.8% for the PR group. What then can explain the observed differences in the results? The poorer graft and patient survival rates observed only 30 days after transplantation are difficult to ascribe solely to the insurance type, lower SES, or social factors. Technical variant deceased donor transplants were more frequently performed in the PU group, and it is well known that technical variant transplants are associated with more vascular