Sociodemographic Determinants of Waitlist and Posttransplant Survival Among End-Stage Liver Disease Patients

Abstract

While regional organ availability dominates discussions of distribution policy, community-level disparities remain poorly understood. We studied micro-geographic determinants of survival risk and their distribution across Donor Service Areas (DSAs). Scientific Registry of Transplant Recipients records for all adults waitlisted for liver transplantation 2002-2014 were reviewed. The primary exposure variables were county-level sociodemographic risk, as measured by the Community Health Score (CHS), a previously-validated composite index local health conditions, and distance to listing transplant center. Among 114 347 patients, the median CHS was 19.4 (range: 0-40). Compared the lowest risk counties (CHS 1-10), highest-risk counties (CHS 31-40) had more black (14.6% vs. 5.4%), publicly insured (44.9% vs. 33.0), and remote candidates (34.0% vs. 15.1% living >100 miles away). Higher-CHS candidates had greater waitlist mortality in Cox multivariable (HR 1.16 for CHS 31-40, 95% CI 1.11-1.21) and competing risks analysis (sHR 1.07, 95% CI 0.99-1.14). Post-transplant survival was similar across CHS quartiles. Living >25 miles from the transplant center conferred excess mortality risk (sHR 1.08, 95% CI 1.03-1.12). Proposed distribution changes would disproportionately impact DSAs with more high-CHS or distant candidates. Low-income, rural and minority patients experience excess mortality while awaiting transplant, and risk disproportionately worse outcomes with reduced organ availability under current proposals.

Barriers to access in pediatric living‐donor liver transplantation

“…The association between specific sociodemographic characteristics and reduced use of LDLT have been reported elsewhere . In a large registry study of children with biliary atresia, individuals with public insurance had significantly lower rates of LDLT, which is not surprising given that public insurance can serve as a proxy for lower income and fewer resources, alongside the observation that living donation is associated with increased financial burden for donors .…”

“…The association between specific sociodemographic characteristics and reduced use of LDLT have been reported elsewhere. 27 In a large registry study of children with biliary atresia, individuals with public insurance had significantly lower rates of LDLT, which is not surprising given that public insurance can serve as a proxy for lower income and fewer resources, alongside the observation that living donation is associated with increased financial burden for donors. 15,19 Here, we explore in greater detail other potential mechanisms that may act as barriers, including that this population is less likely to know the steps for living-donor evaluation, to feel generally well-informed about LDLT, to understand how LDLT may impact their work and other responsibilities, and to know someone that had gone through the process.…”

Public attitudes toward contemporary issues in liver allocation

“…20 We found significant evidence that the public places priority on local donation and argue this needs to be incorporated into allocation decisions. 20 We found significant evidence that the public places priority on local donation and argue this needs to be incorporated into allocation decisions.…”

State‐Based Liver Distribution: Broad Sharing With Less Harm to Vulnerable and Underserved Communities Compared With Concentric Circles

“…For each DSA, data from the Centers for Disease Control and Prevention were obtained for the number of deaths among persons age 15‐74 years with cause of death related to ESLD or hepatocellular carcinoma, as previously described . These county‐level data were aggregated to the DSA level.…”

“…For each DSA, data from the Centers for Disease Control and Prevention were obtained for the number of deaths among persons age 15-74 years with cause of death related to ESLD or hepatocellular carcinoma, as previously described. (17,18) These county-level data were aggregated to the DSA level. The number of adult liver transplant wait-list additions within the DSA was calculated on the basis of the SRTR data relative to adult liver disease deaths.…”