Communication and trust: Critically important to eliminate disparities in liver transplantation

Abstract

Access to liver transplantation is limited by many factors including insurance status, socioeconomic status, (1) geographic location, (2) and the declining availability of quality grafts from suitable donors. (3) Recent studies also suggest racial disparities in access to liver transplantation. (4) For example, despite living closer to transplant centers, blacks are less likely to be referred for transplant. (5,6) If referred, blacks present with a higher Model for End-Stage Liver Disease score than whites, (5) reflecting possible delays in the referral process. Patient perceptions, outcome expectancies, and preferences for medical care explain some of the disparities in other areas of medicine. Yet, little is known about the extent to which patient perceptions and concerns contribute to racial differences in access to liver transplantation.In the current issue of Liver Transplantation, Wilder et al. (7) characterized patient preferences and patientperceived concerns about liver transplantation and organ donation. The authors conducted a survey of 109 patients with advanced liver disease. Of these, 37 patients were listed for liver transplant and 72 were eligible for but not yet listed-the latter group was identified based on review of patients' medical records. In addition to collecting information on patient sociodemographics, the survey included items from the religious beliefs/Duke Religious Index and Health Care System Distrust scale, as well as questions regarding preferences and understanding of liver transplantation and organ donation.Listed participants were better educated and had higher income than nonlisted participants. Not surprisingly, listed patients were more likely to have had a conversation with their physician about liver transplant. They were also more likely to have been referred to a liver transplant center and to understand the requirements for listing and the process of organ distribution than unlisted participants. In contrast, there was no difference in the mean distrust score or religiosity between listed and nonlisted patients. Financial concerns, diagnostic testing, and travel were not considered as barriers to transplantation. Both listed and nonlisted patients desired a liver transplant if recommended and felt that liver transplant would improve their quality of life.The authors found significant racial differences in access to liver transplantation as well as preferences for organ donation, regardless of the listing status. Only 44% of blacks had been referred to a transplant center compared to 70% of whites. However, once referred to the transplant center, nearly 100% of blacks presented to the transplant center comparable to the rate in whites. Blacks, however, were also less familiar with the requirements for listing or the process of organ distribution. This finding was likely influenced by patients' listing status; significantly fewer blacks were listed compared to whites (22.2% versus 35.5%, respectively).Disparities by race are common in many medical conditions. The curren...