A. Ehsan1, A. Zeymo3,4, N. M. Shara3,5, F. W. Sellke1, R. Yousefzai6, W. B. Al-Refaie2,3,4 1Brown University Medical School/Rhode Island Hospital,Division Of Cardiothoracic Surgery,Providence, RI, USA 2MedStar-Georgetown University Medical Center,Department Of Surgery,Washington, DC, USA 3MedStar Health Research Institute,Washington, DC, USA 4MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 5Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 6Brown University School of Medicine/Rhode Island Hospital,Division Of Cardiology,Providence, RI, USA
Introduction: Continuous flow left ventricular assist device (CF-LVAD) implantation is a payor sensitive procedure influenced by preoperative co-morbidities and social factors. Whether expansion in insurance coverage will further influence device utilization is unknown. We sought to assess the effects of Medicaid Expansion on vulnerable populations (namely racial/ethnic minorities and those with low income status) undergoing CF-LVAD implantation after the enactment of the 2014 Affordable Care Act (ACA).
Methods: The 2012 to Q3 2015 State Inpatient Database (SID) was used for patients who were given a CF-LVAD from expansion states relative (Maryland and Kentucky) to non-expansion states (North Carolina and Florida). Patients who were over 65 and patients with Medicare were excluded, as were patients who had a heart transplant, heart-lung transplant or non CF-LVAD, resulting in a cohort of 555 patients. To detect if there were disparities between race, insurance, and income strata as a result of the ACA Medicaid expansion, Poisson Interrupted Time Series (ITS) were used with three-way interactions and change of slope and intercept parameters at 2014.
Results: Poisson ITS models show that within expansion states, the population of Medicaid and uninsured patients saw an increase in the utilization of LVAD's immediately after ACA expansion, from 2.8 in Q4 2013 to 6.6 Q1 2014 (IRR 2.54, p = 0.253). Utilization eventually decayed to pre-ACA levels, however, ending with 2.94 LVADs in Q3 2015 (IRR 0.920, 95% CI 0.759-1.113). Models testing for racial effect showed no statistically preferential or disparate effects (Immediate effect IRR 1.626, p = 0.545; marginal effect IRR 0.774, p = 0.174). ) (Figure 1).
Conclusion: Despite expanded insurance coverage, these preliminary post-ACA findings demonstrate that utilization of CF-LVADs was not increased in non-elderly racial and ethnic minorities. These preliminary results suggest that insurance coverage alone does not play a role in the eligibility of patients for CF-LVAD, however they deserve additional long-term evaluation. Instead, they point toward the importance of further exploring social, medical and hospital drivers of these disparities.
