Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes

Background: Left ventricular assist device (LVAD) therapy is an increasingly viable alternative for patients who are not candidates for heart transplantation or who are waiting for a suitable donor. We aimed to determine whether there is an association between gender, race/ethnicity, insurance coverage, and neighborhood income, and access to / outcomes of LVAD implantation. We further analyzed whether access to LVAD improved in states that did vs did not expand Medicaid.

Methods and Results: Retrospective cohort study using State Inpatient Databases to identify patients 18-85 years of age admitted for heart failure, cardiogenic shock, or LVAD implantation from 2012-2015. Logistic regression analyses adjusting for age, all the sociodemographic factors above, medical comorbidities, and a hospital random effect were used to quantify odds of receipt of LVADs, as well as outcomes conditional on receiving an LVAD, for the sociodemographic groups of interest. A total of 925,770 patients were included; 3,972 (0.43%) received LVADs. After adjusting for age, comorbidities, and hospital effects, women (adjusted OR (aOR) 0.45 [0.41-0.49]), black patients (aOR 0.83 [0.74-0.92]) and Hispanic patients (aOR 0.74 [0.64-0.87]) were less likely to receive LVADs than whites. Medicare (aOR 0.79 [0.72-0.86]), Medicaid (aOR 0.52 [0.46-0.58]), and uninsured patients (aOR 0.17 [0.11-0.25]) were less likely to receive LVADs than the privately insured, and patients in low-income ZIP codes were less likely than those in higher-income areas (aOR 0.71 [0.65-0.77]). Among those who received LVADs, women (aOR 1.78 [1.38-2.30]), patients of unknown race or race other than white, black, or Hispanic (aOR 1.97 [1.42-2.74]), and uninsured patients (aOR 4.86 [1.92-12.28]) had higher rates of in-hospital mortality. Medicaid expansion was not associated with an increase in LVAD implantation.

Conclusions: There are meaningful sociodemographic disparities in access and outcomes for LVAD implantation. Medicaid expansion was not associated with an increase in LVAD rates.