Fasiha Kanwal1,2,3, Ruben Hernaez1,2,3, Yan Liu1,3, Thomas J Taylor4, Abbas Rana5, Jennifer R Kramer2,3, Aanand D Naik2,3,6, Donna Smith2,3, Tamar Taddei7,8, Steven M Asch4,9. 1. Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas. 2. Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas. 3. Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. 4. Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California. 5. Department of Surgery, Baylor College of Medicine, Houston, Texas. 6. Section of Geriatrics and Palliative Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas. 7. Veterans Administration Connecticut Healthcare System, New Haven. 8. Department of Medicine, Yale University, New Haven, Connecticut. 9. Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California.
Abstract
Importance: Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy. Objective: To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts. Design, Setting, and Participants: This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021. Exposures: Sociodemographic (eg, age, insurance, income), clinical (eg, liver disease etiology, severity, comorbidity), and health care facility (eg, complexity, rural or urban, presence of a liver transplant program) factors were evaluated. Main Outcomes and Measures: Referral, wait-listing, and liver transplantation. Results: Of the 34 494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral. Conclusions and Relevance: In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.
Importance: Organ scarcity means few patients with advanced liver disease undergo a transplant, making equitable distribution all the more crucial. Disparities may arise at any stage in the complex process leading up to this curative therapy. Objective: To examine the rate of and factors associated with referral, wait-listing, and receipt of liver allografts. Design, Setting, and Participants: This retrospective cohort study used linked data from comprehensive electronic medical records and the United Network of Organ Sharing. Adult patients with cirrhosis and a Model for End-Stage Liver Disease with addition of sodium score of at least 15 points between October 1, 2011, and December 31, 2017, were included in the study. Patients were from 129 hospitals in the integrated, US Department of Veterans Affairs health care system and were followed up through December 31, 2018. Statistical analyses were performed from April 28, 2020, to January 31, 2021. Exposures: Sociodemographic (eg, age, insurance, income), clinical (eg, liver disease etiology, severity, comorbidity), and health care facility (eg, complexity, rural or urban, presence of a liver transplant program) factors were evaluated. Main Outcomes and Measures: Referral, wait-listing, and liver transplantation. Results: Of the 34 494 patients with cirrhosis (mean [SD] age, 62 [7.7] years; 33 560 men [97.29%]; 22 509 White patients [65.25%]), 1534 (4.45%) were referred, 1035 (3.00%) were wait-listed, and 549 (1.59%) underwent a liver transplant within 3 years of meeting clinical criteria for transplantation. Patient age of 70 years or older was associated with lower rates of referral (hazard ratio [HR], 0.09; 95% CI, 0.06-0.13), wait-listing (HR, 0.07; 95% CI, 0.04-0.12), and transplant (HR, 0.08; 95% CI, 0.04-0.16). Alcohol etiology for liver cirrhosis was associated with lower rates of referral (HR, 0.38; 95% CI, 0.33-0.44), wait-listing (HR, 0.32; 95% CI, 0.27-0.38), and transplant (HR, 0.30; 95% CI, 0.23-0.37). In addition, comorbidity (none vs >1 comorbidity) was associated with lower rates of referral (HR, 0.47; 95% CI, 0.40-0.56), wait-listing (HR, 0.38; 95% CI, 0.31-0.46), and transplant (HR, 0.28; 95% CI, 0.21-0.38). African American patients were less likely to be referred (HR, 0.82; 95% CI, 0.70-0.95) and wait-listed (HR, 0.73; 95% CI, 0.61-0.88). Patients with lower annual income and those seen in facilities in the West were less likely to be referred (HR, 0.70; 95% CI, 0.53-0.93), wait-listed (HR, 0.48; 95% CI, 0.36-0.64), or undergo a transplant (HR, 0.50; 95% CI, 0.34-0.74). In a review of the medical records for 333 patients who had limited comorbidity but were not referred, organ transplant was considered as a potential option in 176 (52.85%). When documented, medical and psychosocial barriers explained most of the deficits in referral. Conclusions and Relevance: In this cohort study, few patients with advanced liver disease received referrals, were wait-listed, or underwent a transplant. The greatest deficits occurred at the referral step. Although health systems routinely track rates and disparities for organ transplants among wait-listed patients, extending monitoring to the earlier stages may help improve equity and manage potentially modifiable barriers to transplantation.
Authors: Caroline Gray; Jennifer Arney; Jack A Clark; Anne M Walling; Fasiha Kanwal; Aanand D Naik Journal: Soc Sci Med Date: 2022-06-04 Impact factor: 5.379
Authors: Stephanie S Keeling; Malcolm F McDonald; Adrish Anand; Greta E Handing; Lyndsey L Prather; Caroline R Christmann; Prasun K Jalal; Fasiha Kanwal; George Cholankeril; John A Goss; Abbas Rana Journal: Clin Transplant Date: 2022-03-25 Impact factor: 3.456
Authors: Mahmoud M Mansour; Darian Fard; Sanket D Basida; Adham E Obeidat; Mohammad Darweesh; Ratib Mahfouz; Ali Ahmad Journal: Cureus Date: 2022-07-05