Outcome of liver transplantation in adult recipients: Influence of neighborhood income, education, and insurance

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Abstract
Poor socioeconomic status (SES) may be associated with lower survival after liver transplantation. In a previous study, we showed that African-American race was an independent predictor of poor survival, and one of the major criticisms of our study was that we had not adjusted the survival for SES as a confounding variable. The objective of the present study was to determine the posttransplant outcome of adult liver transplant recipients based on neighborhood income, education, and insurance using the United Network for Organ Sharing (UNOS) database from 1987 to 2001. Patients (n = 29,481) were divided into 5 groups based on median income as determined by zip code: <$30,000, $30,001-$40,000, $40,001-$50,000, $50,001-$60,000, and >$60,000). Patients (n = 14,814) were divided into 4 groups based on level of education: higher than bachelor’s degree; college attendance or technical school; high school education (grades 9-12); less than high school education. Insurance payer status (n = 23,440) was divided into Medicaid, Medicare, government agency, HMO/PPO, and private. Cox regression analysis was used to adjust the survival for other known independent predictors such as age, race, UNOS status, diagnosis, and creatinine. Results showed that neighborhood income had no effect on graft or patient survival either in the entire cohort or within different racial groups. Education had only marginal influence on the outcome; survival was lower in those with a high school education than in those with graduate education. Patients with Medicaid and Medicare had lower survival when compared to those with private insurance. African-Americans had a lower 5-year survival when compared to white Americans after adjusting for SES and other confounding variables. In conclusion, neighborhood income does not influence the outcome of liver transplantation. Education had minimal influence, but patients with Medicare and Medicaid had lower survival compared to those with private insurance. (Liver Transpl 2004;10:235-243.)