Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States

Abstract

BaCKgRoUND aND aIMS:The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity. appRoaCH aND ReSUltS: We analyzed two databases retrospectively, the Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases, from 2014 to 2018. We included patients aged 25-64 years who had a primary cause of death of ESLD and were listed for transplant in the CDC WONDER or UNOS database. Our primary outcome was the ratio of listing for LT to death from ESLD-listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between races/ethnicities. There were 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001. States that had an above-mean LDR had a lower transplant to listing ratio but a higher transplant to death ratio. Multivariable analysis confirmed that Black race is significantly associated with a lower LDR and transplant to death ratio.CoNClUSIoNS: Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.

Medicaid Expansion Association With End‐Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage

“…As recently reported by our group, the advantage of using the LDR is that it incorporates both listings for transplantation and mortality from ESLD into a single metric with a higher LDR suggesting more favorable listing rates relative to the number of liver disease deaths (as a measure of need). ( 25 ) In our analysis of the LDR, states that expanded Medicaid had improvements in the annual percent change of the LDR after expansion, whereas the 2 cohorts of states that did not expand Medicaid (either with lenient or restrictive coverage) failed to have improvements. Notably, the relative improvements seen in ESLD mortality rates and the LDR in the expansion states did not occur as a result of increased listings for LT. Rather, listings for LT tended to remain relatively steady or decrease during the entire study period in all cohorts.…”

“…The LDR is a metric that was recently reported by our group and reflects access to transplantation—measuring how effectively states listed patients for LT relative to their mortality rate from ESLD. ( 25 ) That is, a higher LDR may reflect higher relative access to LT listing. LT listings and ESLD mortality data were derived from the UNOS STAR data set and CDC WONDER data set, respectively.…”

Decreased access to pediatric liver transplantation during the COVID‐19 pandemic

“… 11 , 28 , 31 Although the MELD score has eliminated disparities while on the LT WL, black patients are less likely to be referred for LT evaluation, are less likely to pursue care at an LT center, and have lower listing to death and transplant to death ratios. 25 , 29 , 32 Recent studies have also found a significant burden of COVID‐19 infection, as well as lack of access to care during COVID‐19, among racial and ethnic minorities and communities and children disproportionately affected by COVID‐19, structural racism, and poverty. 23 , 33 These groups may also be disproportionately impacted by essential personnel status during COVID‐19 23 , 34 , 35 and by general distrust of the healthcare system and delays in seeking care.…”

Electronic Outpatient Referral System for Liver Transplant Improves Appropriateness and Allows First Visit Triage

“…R ates of referral to liver transplant centers (LTCs) and accessibility to liver transplantation (LT) waiting lists are low, with reported data in the literature of 5% to 21% [1][2][3][4][5] and 4% to 40%, [6][7][8][9][10][11][12] respectively. The reasons for the suboptimal referral rates to LTCs, which are the main cause of reduced access to waiting lists, are many.…”