State-Level Geographic Disparities in Liver Transplant Access: Waitlist Outcome Patterns

Background/Objectives: Geographic inequity remains a persistent concern in liver transplantation, particularly for patients requiring liver transplantation for advanced chronic liver disease, in which transplantation remains the definitive therapy for advanced disease. We evaluated state-level differences in liver transplant waitlist burden using publicly available U.S. data. Methods: We performed a retrospective ecological panel study using publicly available United Network for Organ Sharing (UNOS)-derived annual state tables from 1995 to 2025. Six analyzable states were grouped as higher-rurality/substantial-rural-population states (Texas, North Carolina, Pennsylvania) and urban-dominant states (California, New Jersey, Massachusetts). Primary outcomes were annual liver transplants, death removals, and death-share (death removals divided by death removals plus transplants). Descriptive comparisons, era analyses, and heteroscedasticity-robust regression models were performed. Results: The final dataset contained 186 state-year observations. Across 1995-2025, higher-rurality states had more cumulative transplants than urban-dominant states (39,471 vs. 34,178) and fewer cumulative death removals (8642 vs. 10,625). Mean death-share was lower in higher-rurality states (18.7% vs. 22.6%), as was the death-to-transplant ratio (0.219 vs. 0.311). From 2020 to 2025, higher-rurality states again demonstrated lower mean death-share (9.5% vs. 14.3%). In regression modeling, higher-rurality group membership was associated with lower death-share (β = -0.0389, 95% CI -0.0604 to -0.0175, p < 0.001), while the post-2020 era was independently associated with lower death-share (β = -0.1091, 95% CI -0.1299 to -0.0882, p < 0.001). Highly rural low-volume states initially considered for analysis had sparse or suppressed counts and could not be reliably modeled. Conclusions: In this six-state ecological study, higher-rurality states with substantial rural populations exhibited lower waitlist death-removal burden than urban-dominant comparators. These discoveries probably indicate the varying transplant-system configurations instead of the individual rural access being better. The ecological data related to the public can be the basis for significant hypotheses concerning the transplant discrepancies, but the exhaustive consecutive tasks need to be supplemented by static national studies that are patient-level and relevant to rurality, travel distance, PSC-specific cohorts, and psychosocial determinants.