National survey of second opinions for hospitalized patients in need of liver transplantation

Abstract

Aim: Decisions about patient candidacy for liver transplant (LT) can mean the difference between life or death. We surveyed LT centers across the US to assess their perceptions of and barriers to second opinion referrals for inpatients declined for transplant. Methods: The medical and surgical directors of 100 unique US LT programs that had done >20 LTs in 2021 were surveyed with a 33-item questionnaire including both multiple choice and free response questions. Results: The response rate was 60% (60 LT centers) and included 28 larger volume ( ≥ 100 LTs in 2021) and 32 smaller volume ( < 100 LTs in 2021) programs. The top 3 reasons for inpatient denial for LT included lack of social support (21%), physically frailty (20%), and inadequate remission duration from alcohol use (11%). 25% of programs reported “frequently” facilitating a second opinion for a declined inpatient, 52% of programs reported “sometimes” doing so, and 7% of programs reported never doing so. 100% of programs reported that they receive referrals for second opinions. 25% of programs reported transplanting these referrals frequently (over 20% of the time). Neither program size nor program location statistically impacted the findings. When asked if centers would be in favor of standardizing the evaluation process, 38% of centers would be in favor, 39% would be opposed, and 23% were unsure. Conclusions: Practices and perceptions of second opinions for hospitalized patients evaluated for LT varied widely across the US. Opportunities exist to improve equity in LT but must consider maintaining individual program autonomy.