The Waitlist Paradox: Center Volume, Offer Acceptance, and Pseudo-Access to Liver Transplantation

Access to liver transplantation and post-transplant outcomes may vary across centers. We examined the association between center volume and waitlist outcomes among U.S. liver transplant programs.

Adult liver transplant programs were identified using Scientific Registry of Transplant Recipients program-specific reports and stratified into quartiles by deceased donor liver transplant (DDLT) volume. Metrics compared across quartiles included deceased-donor transplant rate ratio (DDTR ratio), time-to-transplant ratio, modeled offer acceptance ratio (OAR), waitlist outcomes, graft survival hazard ratios (HRs) and were reported as median and interquartile ranges (IQR).

DDLT volume increased from Q1 to Q4 (10 [1-33] vs 315 [267-357]; p<0.001). Low-volume centers had lower DDTR ratio (0.35 [0.25-0.82] vs 1.36 [1.02-2.01]; p<0.001) and higher time-to-transplant ratios (1.69 [0.79-2.83] vs 0.82 [0.54-1.34]; p=0.043), while observed waitlist death rates were similar. Overall, OAR increased with volume (Q1 0.51 [0.31-1.05] vs Q4 1.20 [1.13-1.56]), including for PHS high-risk offers, hard-to-place offers, and donors >500 miles away (all p<0.001). Low-volume centers had lower deceased-donor waitlist transplant proportions (31.45% [20.00-41.23] vs 53.62% [46.46-59.86]) and overall waitlist transplant proportions (32.52% [20.50-44.35] vs 55.74% [49.40-61.54]), with higher removals for clinical deterioration, though similar waitlist death percentages (p=0.268).

Low-volume centers demonstrated lower transplant rates, longer time to transplantation, and lower offer acceptance despite similar waitlist mortality, indicating lower realized access to transplantation among waitlisted candidates. These program-level associations warrant further investigation of candidate selection, offer availability, allocation pathways, and program resources before specific interventions are recommended.