Black Patients Disproportionately Left Off Liver Transplant Waitlists

By Megan Brooks

January 15, 2021

NEW YORK (Reuters Health) - Liver-transplant waitlists at many U.S. centers under-represent Black patients compared with what would be expected based on their service area, new research suggests.

This is "concerning," said Dr. Ali Zarrinpar of the Division of Transplantation and Hepatobiliary Surgery at the University of Florida, in Gainesville, noting that donor organs are a "precious resource (and) we as a community need to ensure that they are equitably shared."

"While a number of previous studies have demonstrated disparities in liver-transplantation listing, they were done on a nationwide basis. We were looking for a way to understand whether center- or geography-specific characteristics could explain the disparities," he told Reuters Health by email.

The researchers reviewed deceased donor liver-transplant and waitlist data from 109 high-volume liver-transplant centers. They used five-year U.S. Census Bureau estimates to calculate demographics from each center's geographic donor service area.

Among more than 30,000 patients on the waitlists, 69% were white, 8% were Black, 17% were Hispanic and 6% were in other racial/ethnic groups. By comparison, the Census data showed that these centers served patients who were 62% white, 12% Black, 18% Hispanic and 9% other racial/ethnic groups.

"We found that the Black population was underrepresented at the vast majority of centers, meaning that the percentage of the Black population in a donor service area - the geographic area the center serves - was significantly higher than the percentage of the Black population on waitlists," Dr. Zarrinpar said in a news release.

"A potentially alarming finding derived from the data is that disparities in listing non-Hispanic Blacks increase with increasing percentage of non-Hispanic Blacks in the donor service area population," the researchers note in the Journal of the American College of Surgeons.

"Whether this is due to increasing inequalities in access to care in the larger Black populations around the country, or due to worse functional segregation in these areas independent of poverty or socioeconomic levels, demands closer examination," they point out.

Racial disparities in transplantation are "greatly diminished" once an individual makes it onto the waitlist, the researchers report.

The researchers also identified factors that contribute to liver transplant waitlist disparities. One is health insurance. The more each center transplanted people with private insurance, the less they were representative of the Black population in the donor service area.

"The question of private versus public insurance is interesting and difficult to dissect. It is unclear whether this is just a reflection of patient access or whether it is a conscious decision by hospitals and health systems as to what types of insurance to favor," Dr. Zarrinpar told Reuters Health.

Another contributing factor is travel distance. The longer amount of time patients had to travel to get to the center, the less the center was representative of the percentage of the Black population in their donor service area.

"This measure is also a bit complicated," Dr. Zarrinpar said. "It could mean that the center is the only one around for many miles and so patients have to travel far to get there. This certainly disadvantages the poorer patients who do not have the resources to travel more than 200-300 miles for transplantation and all the intense follow-up. It could also mean that the center is a destination for people from around the country (and perhaps the world). Given the very small number of international transplant recipients, it is more likely that domestic travel is more important."

A potential lack of knowledge among patients and providers (and referral to a transplant center) may also be at play in waitlist disparities.

"Are patients getting to transplant centers to be evaluated and listed appropriately or are they being pre-emptively ruled out without that referral? This could be due to patient lack of primary care or specialty care. Patients may not have these conduits to transplant centers, or perhaps the primary-care physicians do not know about or are themselves pre-emptively ruling out patients who they think may not be transplantable. Some of this can be remedied by an educational and outreach campaign. However, the lack of primary care for patients cannot be fixed as easily," Dr. Zarrinpar told Reuters Health.

SOURCE: Journal of the American College of Surgeons, online January 11, 2021.