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

Area of Science:

• Transplantation research
• Public health policy
• Organ donation disparities

Background:

• Geographic inequities in liver transplantation persist, especially for advanced chronic liver disease patients.
• Liver transplantation is the definitive treatment for end-stage liver disease.
• Evaluating state-level differences in liver transplant waitlist burden is crucial.

Purpose of the Study:

• To assess state-level variations in liver transplant waitlist burden.
• To compare waitlist outcomes between higher-rurality and urban-dominant states in the U.S.
• To identify factors influencing geographic disparities in liver transplantation.

Main Methods:

• Retrospective ecological panel study utilizing United Network for Organ Sharing (UNOS) data (1995-2025).
• Six states categorized into higher-rurality/substantial-rural-population and urban-dominant groups.
• Analysis of annual liver transplants, death removals, and death-share using regression models.

Main Results:

• Higher-rurality states had more transplants and fewer death removals than urban states.
• Mean death-share was significantly lower in higher-rurality states (18.7%) compared to urban states (22.6%).
• Post-2020 era and higher-rurality group membership were independently associated with lower death-share.

Conclusions:

• Higher-rurality states demonstrated a lower liver transplant waitlist death-removal burden.
• Observed differences likely reflect variations in transplant system configurations rather than individual rural access.
• Public ecological data can inform hypotheses on transplant disparities, necessitating patient-level national studies.