Factors Associated With Liver Transplant Referral Among Patients With Cirrhosis at Multiple Safety-Net Hospitals

Abstract

ImportanceA high proportion of underserved patients with cirrhosis receive care at safety-net hospitals (SNHs). While liver transplant (LT) can be a life-saving treatment for cirrhosis, data on referral patterns from SNHs to LT centers are lacking.ObjectiveTo identify factors associated with LT referral within the SNH context.Design, Setting, and ParticipantsThis retrospective cohort study included 521 adult patients with cirrhosis and model for end-stage liver disease–sodium (MELD-Na) scores of 15 or greater. Participants received outpatient hepatology care at 3 SNHs between January 1, 2016, and December 31, 2017, with end of follow-up on May 1, 2022.ExposuresPatient demographic characteristics, socioeconomic status, and liver disease factors.Main Outcomes and MeasuresPrimary outcome was referral for LT. Descriptive statistics were used to describe patient characteristics. Multivariable logistic regression was performed to evaluate factors associated with LT referral. Multiple chained imputation was used to address missing values.ResultsOf 521 patients, 365 (70.1%) were men, the median age was 60 (IQR, 52-66) years, most (311 [59.7%]) were Hispanic or Latinx, 338 (64.9%) had Medicaid insurance, and 427 (82.0%) had a history of alcohol use (127 [24.4%] current vs 300 [57.6%] prior). The most common liver disease etiology was alcohol associated liver disease (280 [53.7%]), followed by hepatitis C virus infection (141 [27.1%]). Median MELD-Na score was 19 (IQR, 16-22). One hundred forty-five patients (27.8%) were referred for LT. Of these, 51 (35.2%) were wait-listed, and 28 (19.3%) underwent LT. In a multivariable model, male sex (adjusted odds ratio [AOR], 0.50 [95% CI, 0.31-0.81]), Black race vs Hispanic or Latinx ethnicity (AOR, 0.19 [95% CI, 0.04-0.89]), uninsured status (AOR, 0.40 [95% CI, 0.18-0.89]), and hospital site (AOR, 0.40 [95% CI, 0.18-0.87]) were associated with lower odds of being referred. Reasons for not being referred (n = 376) included active alcohol use and/or limited sobriety (123 [32.7%]), insurance issues (80 [21.3%]), lack of social support (15 [4.0%]), undocumented status (7 [1.9%]), and unstable housing (6 [1.6%]).ConclusionsIn this cohort study of SNHs, less than one-third of patients with cirrhosis and MELD-Na scores of 15 or greater were referred for LT. The identified sociodemographic factors negatively associated with LT referral highlight potential intervention targets and opportunities to standardize LT referral practices to increase access to life-saving transplant among underserved patients.

Second thoughts about second opinions for liver transplantation

“…A similarly designed study of multiple safety-net hospitals found low rates of referral (28%) associated with active alcohol use, Black race, uninsured status, and other sociodemographic factors. [4] These results demonstrate significant health care disparities and suggest that a process of prereferral selection is occurring.…”

“…Alcohol-associated liver disease, African-American ethnicity, lower annual income, and western US location were associated with lower rates of these LT outcomes. A similarly designed study of multiple safety-net hospitals found low rates of referral (28%) associated with active alcohol use, Black race, uninsured status, and other sociodemographic factors 4 . These results demonstrate significant health care disparities and suggest that a process of pre-referral selection is occurring.…”

Referral for liver transplant following acute variceal bleeding: a multicenter cohort study

“…In a recent American observational cohort, including 521 patients with cirrhosis, Yilma M. et al . found a referral rate for LT evaluation of 27.8% (145/521 patients) and an effective transplant rate within a 5-year follow-up period of 5.4% (28/521 patients) [15]. In another recent American observational cohort, including 34 494 patients with cirrhosis, Kanwal F. et al .…”

“…study, age ≥70 years and the excess number of comorbidities have also been associated with higher risk for lack of referral for LT evaluation [16]. In other recent American observational cohorts, the following factors were associated with a lower risk of referral for LT assessment: female sex, African-American ethnicity, ALD, active alcohol use or limited sobriety, insurance issues, poor finances, lack of social support, undocumented status, or unstable housing [15–17].…”

Care for Vulnerable Populations with Chronic Liver Disease: A Safety-Net Perspective

“…However, because these statistics are based on inpatient data, they may overrepresent etiologies associated with rapid disease progression and acute decompensation, while underrepresenting etiologies with an indolent course. ALD was also the dominant etiology (53.7%), followed by HCV (27.1%), in a multicenter SNH cohort of outpatient referrals for liver transplantation [23]. The liver disease etiologic profile of safety-net patient populations may depend on the clinical context, though ALD and HCV are leading conditions.…”