Geographic disparities in access to liver transplantation

Abstract

Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities—from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.

The impending hepatology workforce shortage: Ethical considerations for closing the gap

“…[7,8] Patients needing liver transplants from rural areas in the United States have a 20% increased risk of mortality compared to urban areas related to distance from a transplant center and socioeconomic status. [9] Access to care and outcomes for other liver diseases including hepatitis C, MASLD, and alcoholassociated liver disease are variable depending on socioeconomic status, ethnicity, education level, and geographic variability. [9] Hepatology expertise is increasingly scarce and not allocated in any formal structure to address geographic needs despite multiple calls to do so.…”

“…[9] Access to care and outcomes for other liver diseases including hepatitis C, MASLD, and alcoholassociated liver disease are variable depending on socioeconomic status, ethnicity, education level, and geographic variability. [9] Hepatology expertise is increasingly scarce and not allocated in any formal structure to address geographic needs despite multiple calls to do so. The Council on Graduate Medical Education (COGME), an advisory committee to the Health Resources and Services Administration (HRSA), is responsible for tracking and reporting trends in the physician workforce and training.…”