Ability to pay and geographical proximity influence access to liver transplantation even in a system with universal access

Increased Risk of Death for Patients on the Waitlist for Liver Transplant Residing at Greater Distance From Specialized Liver Transplant Centers in the United States

BACKGROUND

We have previously shown that patients listed for orthotopic liver transplantation (OLT) in United Network for Organ Sharing Region 4 (Texas and Oklahoma) have higher waitlist mortality rates when residing more than 30 miles from specialized liver transplant centers (LTC). Considering that findings might only be exclusive for this region with its peculiarities in terms of having the highest land surface extensions, lowest population densities, and largest rural populations. We investigated the entire OLT patient population in the United States to assess if our previous regional findings are nationally validated and if a rural, micropolitan, or metropolitan residence location affects outcome of waitlisted OLT patients in the nation.

METHODS

Patients waiting for OLT in the United States from 2002 to 2012 were stratified by distance from the patients' residence to LTC and by Rural Urban Commuting Area (RUCA) codes classification. Statistical analyses were performed to evaluate risk of mortality on the waitlist and the likelihood to receive an OLT using a Cox proportional hazards model and a generalized additive model with a logistic link.

RESULTS

Survival time and probability of death while on the waitlist for OLT using distance to LTC showed significant increased risk with the distance (P = 0.001 and P < 0.0001, respectively). At the same time, using RUCA classification as the variable did not show significance (P = 0.14 and P = 0.73, respectively).

CONCLUSIONS

Distance from an LTC is a risk factor of mortality on the waitlist for OLT, whereas RUCA classification is not a significant factor.

Liver transplantation in Ireland

The Irish National Liver Transplant program commenced in 1993 in St. Vincent's University Hospital in Dublin. It is an adult-only program and is the only liver transplant program in Ireland. Pediatric recipients are referred to King's College Hospital in the United Kingdom. To date, almost 1000 adult liver transplants have been performed. Current 1-year patient survival is 93%, and 5-year survival is 79%. The program is fully funded by the government health service. There is a close collaboration with the United Kingdom Organ Donation and Transplant Directorate, and there is an arrangement for organ sharing for super-urgent transplants. Traditionally, organ donation rates have been high in Ireland. However, demand for liver transplant has increased over the past 20 years, and waiting lists are now lengthening. Deceased cardiac death donation is now being considered, but there are no plans for living related donor liver transplant. Donor coordinators have recently been appointed to the major hospitals in Ireland, and it is hoped that this initiative will lead to an increase in organ donation rates. Liver Transplantation 22 1014-1018 2016 AASLD.

Are there geographical disparities in access to liver transplantation in Atlantic Canada?

OBJECTIVE

To characterize the patient population served by Atlantic Canada's Multi-Organ Transplant Program liver transplant service over the first five years of activity in its current iteration.

METHODS

Data from a prospective institutional database, supplemented by retrospective medical record review, were used to identify and characterize the cohort of patients assessed for consideration of first liver transplant between December 1, 2004 and December 1, 2009.

RESULTS

In the five-year period after reactivation, the program assessed 337 patients for first liver transplant. The median age at referral for this group of 199 men (59.0%) and 138 women (41.0%) was 56.1 years (range 16.3 to 72.3 years). The leading three liver diseases indicating liver replacement were alcohol-related end-stage liver disease (20.5%), hepatocellular cancer (16.6%) and hepatitis C-related end-stage liver disease (14.0%). When evaluated according to provincial population-standardized incidence, significant differences in the incidence of liver transplant assessment among the four Atlantic Canadian provinces were found (per 100,000 inhabitants: Nova Scotia 19.8, New Brunswick 13.0, Newfoundland and Labrador 9.1 and Prince Edward Island 11.0; Fisher's exact P<0.001). Of the 337 individuals who began the assessment process, 153 (45.4%) were assigned to the wait list. The probability of an individual being assigned to the wait list was not found to differ according to province of residence (Nova Scotia 45.3%, New Brunswick 40.0%, Newfoundland and Labrador 58.7% and Prince Edward Island 40.0%; Fisher's exact P=0.206).

CONCLUSIONS

The analysis suggests that there are geographical disparities in access to liver transplantation in Atlantic Canada. These disparities appear to be related to factors that precede the transplant assessment process.

Socioeconomic factors affect disparities in access to liver transplant for hepatocellular cancer

Objective. The incidence/death rate of hepatocellular cancer (HCC) is increasing in America, and it is unclear if access to care contributes to this increase. Design/Patients. 575 HCC cases were reviewed for demographics, education, and tumor size. Main Outcome Measures. Endpoints to determine access to HCC care included whether an eligible patient underwent liver transplantation. Results. Transplant patients versus those not transplanted were younger (55.7 versus 61.8 yrs, P < 0.001), males (89.3% versus 74.4%, P = 0.013), and having completed high school (10.1% versus 1.2%, P = 0.016). There were differences in transplant by ethnicity, insurance, and occupation. Transplant patients with HCC had higher median income via census classification ($54,383 versus $49,383, P = 0.046) and self-reported income ($48,948 versus $38,800, P = 0.002). Differences in access may be related to exclusion criteria for liver transplant, as Pacific Islanders were more likely to have tumor size larger than 5 cm compared to Whites and have BMI > 35 (20.7%) compared to Whites (6.4%) and Asians (4.7%). Conclusions. Ethnic differences in access to transplant are associated with socioeconomic status and factors that can disqualify patients (advanced disease/morbid obesity). Efforts to overcome educational barriers and screening for HCC could improve access to transplant.

Increase in mortality rate of liver transplant candidates residing in specific geographic areas: analysis of UNOS data

We sought to evaluate survival of liver transplant candidates living in geographic areas with limited access to specialized transplant centers (TxC). We analyzed survival outcome among candidates listed for liver transplant in United Network of Organ Sharing (UNOS) Region 4 from 2004 to 2010. Candidates were stratified into three groups according to the distance from the patient's residence to the closest hospital with a liver transplant program: Group 1 (Gr 1) <30 miles (m), Group 2 (Gr 2) 30-60 m and Group 3 (Gr 3) >60 m. Of the 5673 patients included in the study, 49% resided >30 m from a TxC. Eight percent of the cohort experienced death or dropped out of the list due to medical condition deterioration, with worse outcomes for Gr 2 and Gr 3 (8.5% and 9.9%, respectively, vs. 6.5% for Gr 1 [p < 0.001]). Among patients with a MELD score <20, mortality was higher in Gr 2 and Gr 3 compared to Gr 1 (p < 0.001). We conclude that for Region 4, the mortality risk in patients living >30 m from a TxC is higher. We suggest that the variable "distance from a TxC" should be used to improve the estimate of the mortality risk for patients on the waiting list.

Immune factors influencing ethnic disparities in kidney transplantation outcomes

An influence of ethnicity on the outcomes of kidney transplant recipients has been recognized for several decades. Both immune and nonimmune factors have been explored as potential explanations. Most studies have focused on the inferior outcomes of African-Americans. As a group, African-Americans differ from Caucasians with respect to a number of measurable components of the alloimmune response, including the T-cell repertoire and the expression and function of costimulatory molecules and various cytokines and chemokines. In general, these differences suggest that African-Americans may be high immune responders. However, no single difference in any of these components of alloimmunity satisfactorily explains the disparities in outcomes. It seems probable that some combination of immune factors interacts with nonimmune factors, such as socioeconomic resources, to influence transplant outcomes in a complex manner.

Rural residency and the risk of mortality while waiting for liver transplantation

Our liver transplant program services a region that has a prominent rural demographic. The influence of rural residency on liver transplant wait-list mortality has not been previously studied. We hypothesized that residence in a rural setting, by imposing challenges to medical care access, might be associated with inferior survival while waiting for liver transplantation. To test this hypothesis, multivariable time-to-event analysis was performed using Cox proportional hazards and competing risks regression on data from a consecutive five-yr cohort of 159 primary liver transplant candidates, to derive covariate adjusted effect measures for the association between residence in a rural area and wait-list mortality. For the primary analysis, a standardized, census-based, definition was used to assign rural residency status. The Kaplan-Meier estimated 90-d and one-yr wait-list mortality for the cohort was 7.6% (95% CI: 4.2-13.8) and 15.6% (95% CI: 9.4-25.2). The covariate adjusted hazard ratio for the relationship between Rural and Small Town residency status and wait-list mortality was 0.497 (95% CI: 0.171-1.438, p = 0.197) for the Cox regression model and 0.628 (95% CI: 0.224-1.757, p = 0.376) for the competing risk regression model. As defined in this study, candidate residence in a rural setting was not found to be associated with inferior survival while awaiting liver transplantation.

Liver transplantation trends in the HIV population

There is a paucity of information on the utilization patterns of liver transplantation (LT) for HIV-positive individuals. The aim of this study is to examine the trends in LT of HIV patients in the US. This study was a retrospective analysis using the UNOS database (1999-2008). There were 135 HIV-positive patients. There was a steady increase in the number of LT recipients over time as well as regional variation. Ethnic minorities accounted for 33.3% and there was no ethnic difference in survival. Though LT for HIV-positive patients is on the rise, significant variations exist in patient demographics, geographic location, and insurance payer.

Liver transplantation in the ethnic minority population: challenges and prospects

In the USA, end-stage liver disease (ESLD) is a major cause of morbidity and mortality among ethnic minorities. Ethnic populations vary with respect to chronic liver disease prevalence, access to transplantation, and therapeutic outcomes post liver transplantation. These ethnic differences present unique challenges to healthcare professionals involved in the care of patients with chronic liver disease prior and post transplantation. This review will discuss the variations and challenges of liver transplantation in the ethnic minority population.

Greater travel time to a liver transplant center does not adversely affect clinical outcomes

The effect of patient travel time to a transplant center on outcomes is unknown. We compared outcomes between patients living >3 hours (Group A) vs. <or=3 (Group B) hours drive away. Adult, nonacute liver failure patients entering transplant evaluation from February 27, 2002 to January 31, 2005 were analyzed. Of 166 patients, 126 (75.5%) were listed and 66 (39.5%) received transplantation. Outcomes of interest were >90 days to list, listing, survival while listed, transplantation, and posttransplantation survival. Covariates included Model for End-Stage Liver Disease (MELD) score, hepatocellular carcinoma (HCC), alcoholic liver disease, insurance type, and psychosocial score. There were 38 (23%) patients in Group A and 128 (77%) in Group B. Median MELD scores were 14.5 (range, 6-36) for Group A and 14.0 (range, 7-32) for Group B (p = 0.20). Groups were similar for age, gender, diagnosis, psychosocial score, insurance, and HCC variables. Group A was not independently associated with >90 days to list (odds ratio, 0.98; 95% confidence interval [CI], 0.4-2.4). Kaplan-Meier cumulative probabilities for listing, transplantation, and 1-yr posttransplantation survival were similar (A vs. B: 0.77 vs. 0.83, 0.70 vs. 0.69, and 0.85 vs. 0.86, respectively; all p values >0.05). Being in Group A remained insignificant in terms of probability of listing, transplantation, and posttransplantation survival by Cox proportional hazard modeling. Survival on the list was significantly better for Group A (A: 1.0, B: 0.55; p = 0.02). Fewer patients at high MELD score in Group A and referral biases may explain this difference. In conclusion, after entering evaluation, patients living >3 hours away from a transplant center have comparable outcomes to those living closer.

Referrals for surgical therapy in patients with hepatocellular carcinoma: a community experience

The treatment of hepatocellular carcinoma (HCC) is notoriously difficult. Either because of oncogenic behavior or the frequent association of cirrhosis, successful therapy is elusive, particularly in cirrhotic patients. Surgical removal has been the only modality that has produced long-term, disease-free survival. In a large series of patients from specialty institutions, median survival in those who underwent resection of HCC lesions has ranged from 30 to 70 months. Similarly, liver transplantation has been shown to be an effective treatment when HCC is favorable (limited in size and number), producing long-term survival in greater than 70% of patients. However, less information is known about community-based treatment of HCC. Reports from referral centers may not accurately reflect the community experience. We have retrospectively reviewed patients with HCC seen in surgical referral from three teaching hospitals in a medium-size urban community from 1995 to 2004 who were not felt to be candidates for liver transplantation and who were not sent to referral centers. We sought to examine their suitability for operation and resection. The study group comprised 61 patients, whose ages ranged from 35 to 83 years old. There were 44 patients (72%) with cirrhosis (Childs A, B, and C in 27, 15, and 2 patients, respectively), 21 from hepatitic C virus (HCV) infection. Three recognized staging systems were used that incorporated the estimation of hepatic reserve and tumor burden. Seven patients (11%) were deemed nonoperable (five advanced disease by imaging, two comorbidities). Of the 54 patients who underwent surgical procedures, 32 underwent resection (28 patients) or cryoablation (4 patients). The reasons for unresectability were unrecognized multifocality (ten patients), poor risk for major hepatectomy (five patients), portal vein/hepatic vein involvement (three patients), metastatic disease (two patients), and excessive blood loss prior to hepatectomy (two patients). Eleven of 17 (65%) noncirrhotic patients and 21 of 44 (48%) cirrhotic patients were resectable or ablatable. There were ten postoperative deaths: six following resection, two following cryoablation, and two following exploratory celiotomy. All deaths were in cirrhotic patients (Childs A in four patients, B in five patients, and C in one patient), 10 of 44 patients (23%); 3 of 11 (27%) patients died following segmentectomy and 3 of 9 (33%) following major hepatectomy. Seven deaths that occurred were in patients with HCV; (P = NS). From this series, the difficulty in surgically treating cirrhotic patients in an urban practice is evident. From 39 to 73% of patients had advanced local disease. Less than half were resectable and, for cirrhotic patients, the postoperative mortality was high, even after "minor" hepatectomies. Noncirrhotic patients fared somewhat better. While HCC in community practice can be treated surgically in the majority of noncirrhotic patients, cirrhotic patients are less likely candidates, and surgical treatment is associated with significant postoperative mortality. This frequently reflected advanced disease and HCV but may be associated with access to preventative and surveillance measures. Only those with optimum hepatic reserve and small tumor burden should be considered for surgical resection.

Disparities in solid organ transplantation for ethnic minorities: facts and solutions

The Diversity and Minority Affairs Committee of the American Society of Transplantation (AST) convened a symposium to examine organ transplantation in underserved and minority populations. The goals of the meeting included 'benchmarking' of solid organ transplantation among minority populations, review of the epidemiology of end-organ damage, exploration of barriers to transplantation services and development of approaches to eliminate disparities. Participants noted that minority populations were more likely to be adversely affected by limited preventive medical care, lack of counseling regarding transplant options, and delays in transplant referrals for organ transplantation. These features largely reflect economic disadvantage as well as the reduced presence of minority professionals with training in transplant-related specialties. Participants in the conference noted that recent changes in organ allocation policies had improved access to minority individuals once listed for renal transplantation. Similar advances will be needed for other organs to address inequities in pretransplant care and underrepresentation of minorities among transplant professionals. The biologic basis of differences in transplant outcomes for minority recipients has not been adequately studied. Research funds must be targeted to address biologic mechanisms underlying disparate transplant outcomes including the impacts of environment, education, poverty and lifestyle choices.