Impact of public versus non public insurance on hispanic kidney transplant outcomes using UNOS database

This study investigated the impact of insurance type on kidney transplant outcomes among Hispanic patients in the United States through the use of the OPTN/UNOS database. Our findings demonstrate that Hispanic kidney transplant recipients with public insurance experienced significantly worse graft survival compared to than those with non-public insurance, even after adjusting for potential confounders. While the unadjusted mortality risk was higher in the public insurance group, this association remained significant but was attenuated after multivariable adjustment, indicating that baseline differences explain part, but not all, of the increased mortality risk. Insurance type did not significantly impact short-term rejection rates (p = 0.07). While this finding was not statistically significant, it suggests a potential area for further investigation to better understand factors influencing rejection rates.

The observed disparities in graft outcomes between public and non-public insurance groups persisted even after accounting for key confounding factors. Our sensitivity analyses, restricted to dialysis-dependent patients and employed individuals, consistently demonstrated that public insurance was independently associated with higher risks of death-censored graft failure and patient death. To ensure the robustness of our findings, we employed both Cox proportional hazard models for death-censored graft failure and Fine and Gray’s competing risk models to account for the competing risk of death. Both approaches yielded consistent results, confirming that public insurance is associated with a higher risk of graft failure. These findings suggest that the disparities are not merely attributable to baseline differences, such as dialysis duration or comorbidities, but likely reflect broader systemic barriers, including fragmented care coordination, reduced access to post-transplant specialists, and potential delays in follow-up appointments for patients with public insurance¹⁸. Previous studies have shown that patients with public insurance face barriers in accessing healthcare services, including transplantation, and may have limited access to specialized care and immunosuppressive medications post-transplant^16,19,20,21. Our findings suggest that these barriers may persist even after successful kidney transplantation and contribute to inferior graft survival in Hispanic patients with public insurance. The higher rates of death-censored graft failure and patient death among recipients with public insurance can be attributed to several factors. Socioeconomic status plays a significant role in health outcomes, and patients with public insurance often have lower socioeconomic backgrounds, which can limit their access to comprehensive post-transplant care^22,23,24,25. Lower health literacy rates among the public insurance patients may also contribute to poorer self-management and adherence to post-transplant care regimens²⁶. Additionally, a higher prevalence of comorbid conditions such as diabetes and peripheral vascular disease among patients with public insurance could adversely affect the transplant outcomes separate from the direct impact of insurance type^27,28. The cumulative result of limited access to high-quality healthcare providers and facilities for those with public insurance could lead to suboptimal care, follow-up, and outcomes²³.

The attenuation of the association between insurance type and mortality after risk factor adjustment suggests that the increased mortality risk in the public insurance group is partially explained by differences in baseline health status and other confounders²⁹. Hispanic patients with public insurance had more comorbidities, lower functional status, and less favorable transplant characteristics than those with non-public insurance. However, even after multivariate adjustments, the association between public insurance and patient death remained statistically significant, albeit attenuated. This finding indicates that factors beyond insurance type play a crucial role in patient survival post-transplant. These factors may include socioeconomic status, underlying health conditions, access to follow-up care, and support systems, which can significantly influence post-transplant outcomes.

The lack of a significant association between insurance type and short-term rejection rates suggests that factors other than immunological risk may be driving disparities in graft survival. Key factors likely include differences in access to care, medication adherence, and long-term management of comorbidities, which disproportionately affect publicly insured patients. Further research is needed to elucidate the specific mechanisms underlying these disparities in graft outcomes among Hispanic kidney transplant recipients and to identify targeted interventions to mitigate these challenges. Intervention-focused research should prioritize improving care coordination for publicly insured patients, expanding access to transplant-specific education programs, and addressing systemic barriers, such as delays in follow-up care, fragmented care pathways, and limited access to specialist providers. Policy-level solutions, such as broadening insurance coverage to include comprehensive post-transplant care, are also critical.

While this study provides valuable insights into the association between insurance type and post-transplant outcomes within the Hispanic population, future research should expand to include recipients of other racial/ethnic backgrounds. Comparative analyses using interaction terms between insurance type and ethnicity could elucidate whether these disparities are unique to Hispanic patients or consistent across other groups. Such studies would deepen understanding of how social determinants of health, healthcare system factors, and cultural barriers interact with insurance type to influence transplant outcomes. Additionally, future research should integrate granular data on social determinants of health, including geographic location, transportation challenges, and cultural barriers, which may also impact access to care and long-term post-transplant management. By developing and testing interventions, such as tailored patient education programs, community-based care models, and culturally competent health services, researchers can help reduce disparities in transplant outcomes. Policy changes aimed at improving healthcare access and continuity of care for patients with public insurance are essential for achieving equitable transplant outcomes.

Our study has several strengths, including the use of a large, nationally representative database in order to focus on a specific minority population with known disparities in transplant outcomes. This broad dataset enhances the generalizability of our findings within the United States and provides valuable insights into the unique challenges faced by Hispanic kidney transplant recipients. However, there are several limitations to this study that must be considered. While this study provides valuable insights, it is not without limitations. First, as an observational study, it precludes definitive causal inferences, and unmeasured confounders may have influenced the results. Second, prior studies have highlighted potential challenges in the accurate reporting of outcomes, including death and graft failure, within the OPTN/UNOS database^30,31. While the database is robust, these challenges underscore the importance of continuous data validation and quality assurance to ensure the reliability of registry-based findings^30,31. Third, the OPTN/UNOS database lacks granular information on critical variables such as socioeconomic status, health literacy, and other social determinants of health, which likely play significant roles in transplant outcomes. Fourth, the absence of cardiovascular disease data in the OPTN/UNOS database is a notable limitation, as cardiovascular disease is a major risk factor for mortality in kidney transplant recipients. Its exclusion limits our ability to comprehensively assess its impact on post-transplant outcomes. Future studies that incorporate datasets with detailed cardiovascular disease information are needed to better understand its influence. Finally, These findings may not be generalizable to non-Hispanic populations or Hispanic patients outside the United States, where healthcare systems, insurance structures, and transplant care pathways may differ substantially. These limitations highlight the need for cautious interpretation of the results and underscore the importance of considering broader contextual factors in future research. Despite these limitations, our findings provide important insights into the role of insurance type in shaping disparities in kidney transplant outcomes among Hispanic patients and underscore the need for further research and targeted interventions in this population.

In summary, this study highlights that medical insurance type is associated with significant disparities in kidney transplant outcomes within the Hispanic population. While our findings provide valuable insights into this underserved group, broader research is needed to assess whether these disparities differ by race/ethnicity. Such comparative analyses could inform targeted interventions to address inequities across all transplant populations and improve outcomes for all patients, regardless of race, ethnicity, or insurance type. Public insurance is associated with higher rates of death-censored graft failure and patient death, even after adjusting for confounders, although the association with patient death is partially attenuated. Addressing these disparities requires a multifaceted approach, including improving healthcare access, enhancing patient education, and addressing socioeconomic determinants of health. Our findings underscore the need for targeted interventions and policies to ensure equitable access to high-quality kidney transplantation care and to improve outcomes for Hispanic patients.