Ethnic and Age Disparities in Outcomes Among Liver Transplant Waitlist Candidates

Mustian, Margaux N.; Shelton, Brittany A.; MacLennan, Paul A.; Reed, Rhiannon D.; White, Jared; Eckhoff, Devin E.; Locke, Jayme E.; Allman, Richard M.; Gray, Stephen H.

doi:10.1097/tp.0000000000002523

Cited by 17 publications

(19 citation statements)

References 38 publications

(35 reference statements)

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“…Despite the role of LT as the gold standard treatment for patients with end‐stage liver disease and select unresectable HCC, ( 1,6 ) disparities in both pre‐ and post‐transplantation outcomes persist. The current study is the first to examine the impact of payer status on delisting across disease etiologies at the national level.…”

Section: Discussionmentioning

confidence: 99%

“…Liver transplantation (LT) is the only definitive therapy for end‐stage liver disease and is considered the standard of care for suitable candidates. ( 1 ) Despite an increasing caseload and broader offer acceptance criteria, LT volume remains surpassed by the number of patients added to the LT waiting list annually in the United States. ( 2,3 ) Importantly, the number of patients who die or are removed from the LT waiting list has increased significantly during the past decade.…”

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confidence: 99%

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Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States

et al. 2020

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Although socioeconomic disparities persist both pre‐ and post‐transplantation, the impact of payer status has not been studied at the national level. We examined the association between public insurance coverage and waitlist outcomes among candidates listed for liver transplantation (LT) in the United States. All adults (age ≥18 years) listed for LT between 2002 and 2018 in the United Network for Organ Sharing database were included. The primary outcome was waitlist removal because of death or clinical deterioration. Continuous and categorical variables were compared using the Kruskal‐Wallis and chi‐square tests, respectively. Fine and Gray competing‐risks regression was used to estimate the subdistribution hazard ratios (HRs) for risk factors associated with delisting. Of 131,839 patients listed for LT, 61.2% were covered by private insurance, 22.9% by Medicare, and 15.9% by Medicaid. The 1‐year cumulative incidence of delisting was 9.0% (95% confidence interval [CI], 8.3%‐9.8%) for patients with private insurance, 10.7% (95% CI, 9.9%‐11.6%) for Medicare, and 10.7% (95% CI, 9.8%‐11.6%) for Medicaid. In multivariable competing‐risks analysis, Medicare (HR, 1.20; 95% CI, 1.17‐1.24; P < 0.001) and Medicaid (HR, 1.20; 95% CI, 1.16‐1.24; P < 0.001) were independently associated with an increased hazard of death or deterioration compared with private insurance. Additional predictors of delisting included Black race and Hispanic ethnicity, whereas college education and employment were associated with a decreased hazard of delisting. In this study, LT candidates with Medicare or Medicaid had a 20% increased risk of delisting because of death or clinical deterioration compared with those with private insurance. As more patients use public insurance to cover the cost of LT, targeted waitlist management protocols may mitigate the increased risk of delisting in this population.

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confidence: 99%

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Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States

et al. 2020

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“…( 80 ) Despite the lack of compelling evidence for poorer outcomes in older adults, advanced age is associated with a lower likelihood of transplantation from the waiting list than younger age. ( 80,81 )…”

Section: Age Disparitiesmentioning

confidence: 99%

A Review of the Current State of Liver Transplantation Disparities

2021

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Equity in access is one of the core goals of the Organ Procurement and Transplant Network (OPTN). However, disparities in liver transplantation have been described since the passage of the National Organ Transplant Act, which established OPTN in the 1980s. During the past few decades, several efforts have been made by the United Network for Organ Sharing (UNOS) to address disparities in liver transplantation with notable improvements in many areas. Nonetheless, disparities have persisted across insurance type, sex, race/ethnicity, geographic area, and age. African Americans have lower rates of referral to transplant centers, females have lower rates of transplantation from the liver waiting list than males, and public insurance is associated with worse posttransplant outcomes than private insurance. In addition, pediatric candidates and older adults have a disadvantage on the liver transplant waiting list, and there are widespread regional disparities in transplantation. Given the large degree of inequity in liver transplantation, there is a tremendous need for studies to propose and model policy changes that may make the liver transplant system more just and equitable.

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“…Тем не менее улучшение функции печени и развитие рекомпенсации происходит время от времени в повседневной клинической практике, даже в среде больных, включенных в ЛО [8]. В частности, изменение парадигмы декомпенсации печени и развитие рекомпенсации стало возможным после внедрения в клиническую практику современных противовирусных средств.…”

Section: Introductionunclassified

Delisting of liver transplant candidates following recompensation of chronic liver diseases – patient characteristics and predictors of delisting: a prospective study

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et al. 2020

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Цель. Определить факторы, предсказывающие развитие рекомпенсации (предикторы) с последующим делистингом, на момент включения пациентов в лист ожидания трансплантации печени. Материалы и методы. Проведено проспективное исследование по типу «случай-контроль». В когорту «случай» вошли 19 взрослых пациентов с декомпенсированными заболеваниями печени различной этиологии, включенных в лист ожидания трансплантации печени и в последующем выбывших из него вследствие рекомпенсации. Когорту «контроль» составили пациенты (n = 61) с декомпенсированными заболеваниями печени, включенные в тот же период времени в лист ожидания, умершие в период декомпенсации. Результаты. Для определения независимых предикторов делистинга вследствие рекомпенсации использовалась логистическая регрессионная модель. Значимыми предикторами рекомпенсации стали параметры альбумина плазмы крови и лейкоцитов крови при включении в лист ожидания (р = 0,024 и р = 0,019 соответственно). Предсказательная ценность выявленных предикторов была подтверждена с помощью ROC-анализа (Receiver Operating Characteristic). Площадь под ROC-кривой (Area Under Curve-AUC) для концентрации альбумина оказалась равной 0,938 [95% доверительный интервал (ДИ) 0,882-0,995; p < 0,001]. AUC ROC для количества лейкоцитов оказалась равной 0,924 [95% ДИ 0,865-0,982; p < 0,001]. Отношение шансов для исхода рекомпенсации, при условии если количество лейкоцитов при включении в лист ожидания ≥3,1 × 10 9 /л, оказалось равным 14,639 (95% ДИ 2,16-99,12). Отношение шансов для исхода рекомпенсации, при условии если концентрация альбумина плазмы крови при включении в лист ожидания ≥39,1 г/л, оказалось равным 3,06 (95% ДИ 1,58-5,95). Заключение. Исследование показало возможность обратимости по врежде ний печени после прекращения действия факторов, вызывающих ее декомпенсацию. Независимыми предикторами развития рекомпенсации и последующего делистинга пациентов оказались количество лейкоцитов крови ≥3,1 × 10 9 /л и концентрация альбумина плазмы крови ≥39,1 г/л на момент включения пациентов в лист ожидания трансплантации печени. Ключевые слова: лист ожидания трансплантации печени, делистинг вследствие рекомпенсации функции печени, предикторы делистинга.

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Ethnic and Age Disparities in Outcomes Among Liver Transplant Waitlist Candidates

Cited by 17 publications

References 38 publications

Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States

Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States

A Review of the Current State of Liver Transplantation Disparities

Delisting of liver transplant candidates following recompensation of chronic liver diseases – patient characteristics and predictors of delisting: a prospective study

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