Only 25% of patients with cirrhosis receive transplant referrals at safety-net hospitals
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Key takeaways:
- The most common reason for nonreferral was active alcohol use or limited sobriety.
- Male sex, Black race, insurance status and hospital site were associated with lower odds of LT referral.
Nearly 75% of patients with end-stage liver disease in safety-net hospitals were not referred for liver transplant evaluation, mostly due to active alcohol use or insurance issues, according to data published in JAMA Network Open.
“Patients with cirrhosis treated at safety-net hospitals have high mortality,” Mignote Yilma, MD, of the department of general surgery at the University of California, San Francisco, and colleagues wrote. “Most current studies focus on identifying factors associated with LT once a patient is referred for evaluation, rather than referral rates among the eligible population with end-stage liver disease, where significant drop-offs are anticipated.”
In a retrospective cohort study, Yilma and colleagues aimed to identify factors associated with LT referral among 521 adult patients (70.1% men; median age, 60 years) with cirrhosis at three safety-net hospitals (SNH) in Los Angeles, San Francisco and Seattle.
Most patients were Hispanic or Latinx (59.7%), had Medicaid insurance (64.9%) and reported current (24.4%) or previous (57.6%) alcohol use. The most common cause of liver disease was alcohol-associated (53.7%), followed by hepatitis C virus infection (27.1%) and nonalcoholic fatty liver disease or nonalcoholic steatohepatitis (8.3%). MELD-Na scores ranged from 15 to more than 25, with a median of 19.
Over a median follow-up of 30 months, 145 patients were referred for LT. Of those, 73.1% were evaluated, 35.2% were waitlisted and 19.3% underwent transplantation. The most common reasons for nonreferral were active alcohol use or limited sobriety (32.7%) and insurance issues (21.3%), followed by clinical improvement (16%), medical comorbidity (8.5%), lack of social support (4%), undocumented status (1.9%) and unstable housing (1.6%).
Multivariable analysis showed male sex (adjusted OR = 0.5; 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 = 0.4; 95% CI, 0.18-0.89) and hospital site (aOR = 0.4; 95% CI, 0.18-0.87) were associated with a decreased likelihood of LT referral.
“In this cohort study, nearly three-fourths of patients with [end-stage liver disease] in SNHs were not referred for LT evaluation,” Yilma and colleagues concluded. “Social determinants of health and [alcohol-associated liver disease] played a large role in nonreferral. In SNH settings that serve the most vulnerable patients, improving LT referral will require a multipronged approach at the patient, clinician and system levels.”
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