Abstract
Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end-stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally-representative databases: HealthCore (2006–2014) and 5-state Medicaid (CA, FL, NY, OH, and PA; 2002–2009). UNOS linkages enabled ascertainment of waitlist and transplant-related outcomes. We included patients aged 18–75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated ICD-9-based algorithms. Among 16,824 ESLD HealthCore patients, 3-year incidences of waitlisting and transplantation were 15.8% (95% CI: 15.0–16.6%) and 8.1% (7.5–8.8%), respectively. Among 67,706 ESLD Medicaid patients, 3-year incidences of waitlisting and transplantation were 10.0% (9.7–10.4%) and 6.7% (6.5–7.0%), respectively. In HealthCore, the absolute ranges in states’ waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6–38.5%, ESLD 3-year mortality: 48.9–62.0%; waitlist transplant rates: 36.3–72.7%, ESLD transplant rates: 4.8–13.4%). States’ waitlist mortality and ESLD population mortality were not positively correlated: ρ=−0.06, p-value=0.83 (HealthCore); ρ=−0.87, p-value=0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (ρ=0.36, p-value=0.55), but were positively correlated in HealthCore (ρ=0.73, p-value=0.001). Compared to population-based metrics, waitlist-based metrics overestimate geographic disparities in access to liver transplantation.
