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Access to the Liver Transplant Waitlist in Patients With HCC: A National EHR Study of Center Level Variation among
Conor B Donnelly1,2, Michal Mankowski1, Kelly Terlizzi1
1Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA.
Insights
Prompt liver transplantation (LT) waitlisting is crucial for hepatocellular carcinoma (HCC) patients. However, only a fraction are listed, with significant variation based on non-clinical factors, indicating access barriers.
Area of Science:
- Hepatology
- Transplant Surgery
- Health Services Research
Background:
- Prompt waitlisting for liver transplantation (LT) is critical for hepatocellular carcinoma (HCC) patients due to a mandatory 6-month waiting period for exception points.
- Access to LT for HCC patients is influenced by timely addition to the waitlist.
Purpose of the Study:
- To analyze the rates of LT waitlisting among patients with HCC.
- To identify patient-level and center-level factors associated with waitlisting.
- To examine variations in waitlisting rates across different transplant centers.
Main Methods:
- Utilized Epic Cosmos data for patients with HCC referred for LT between January 2018 and October 2024.
- Employed modified Poisson regression to calculate waitlisting rates.
- Assessed individual factors (socioeconomic status, insurance, marital status, age) and center-level variations.
Main Results:
- Of 11,422 referred HCC patients, 71.5% initiated evaluation, and 57.6% were waitlisted.
- Older age (70+), Medicaid insurance, never-married status, and lower socioeconomic status were associated with lower waitlisting rates.
- Significant center-level variation in waitlisting rates was observed, with 13% of centers listing patients at rates substantially below the national median.
Conclusions:
- A small proportion of referred HCC patients are placed on the LT waitlist.
- Non-clinical factors significantly impact waitlisting access, highlighting systemic barriers.
- Transplant centers must implement interventions to reduce these barriers and improve equitable access to LT for HCC patients.
Background:
As a 6-month waiting period is required to receive exception points to prioritize patients with hepatocellular carcinoma (HCC) for liver transplantation, prompt addition to the waitlist is critical in access to LT.
Methods:
Using Epic Cosmos data on patients with HCC referred for LT 1/2018-10/2024, we used modified Poisson regression to calculate rates of waitlisting. Center-level and individual (socioeconomic, geographic, and insurance) factors were measured among those who progressed.
Results:
Among 11,422 HCC patients referred for LT at 70 centers, with median age 63 [IQR: 58, 68], 71.5% initiated evaluation and, of those who began evaluation, 57.6% were waitlisted for LT. Of those referred, patients who were older (age 70+ vs. 51-60; RR 0.77, 95% CI: 0.65-0.90, p < 0.001), on Medicaid (0.83, 95% CI: 0.71-0.97, p = 0.02), never-married (0.82, 95% CI: 0.73-0.91, p < 0.001), or low SES (Q4: 0.87, 95% CI: 0.77-0.97, p = 0.002) had lower rates of waitlisting. Among waitlisted patients, median time from referral was 3.3 months [IQR: 2.0, 5.3]. Despite adjustment for patient level covariates, there was high center-level variation in rate of waitlisting within 12 months; 13% of centers listed patients at a rate ≥ 20% below the national median.
Conclusion:
Only a fraction of referred patients with HCC are waitlisted for LT. High variation in access to waitlisting based on non-clinical factors suggests barriers to waitlisting that must be addressed. Centers should focus on interventions to reduce barriers to waitlisting in patients with HCC.
