Author information
1Division of Gastroenterology, Department of Medicine, University of Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania. Electronic address: david.goldberg@uphs.upenn.edu.
2Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania.
3Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania.
4HealthCore, Inc.
5Division of Gastroenterology, Department of Medicine, University of Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania.
6Division of Gastroenterology, Department of Medicine, University of Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania.
7Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania.
Abstract
BACKGROUND & AIMS:
Despite recent attention to differences in access to livers for transplantation, research has focused on patients already on the waitlist. We analyzed data from a large administrative database that represents the entire US population, as well as state Medicaid data, to identify factors associated with differences in access to waitlists for liver transplantation.
METHODS:
We performed a retrospective cohort study of transplant-eligible patients with end-stage liver disease using the HealthCore Integrated Research Database (2006-2014; n=16,824) and Medicaid data from 5 states (2002-2009; CA, FL, NY, OH, and PA; n=67,706). Transplant-eligible patients had decompensated cirrhosis, hepatocellular carcinoma (HCC), and/or liver synthetic dysfunction, based on validated ICD-9-based algorithms and data from laboratory studies. Placement on the waitlist was determined through linkage with the Organ Procurement and Transplantation Network database.
RESULTS:
In an unadjusted analysis of the HealthCore database, we found that 29% of patients with HCC were placed on the 2 year waitlist (95% CI, 25.4%-33.0%) compared to 11.9% of patients with stage 4 cirrhosis (ascites) (95% CI, 11.0%-12.9%) and 12.6% patients with stage 5 cirrhosis (ascites and variceal bleeding) (95% CI, 9.4%-15.2%). Among patients with each stage of cirrhosis, those with HCC were significantly more likely to be placed on the waitlist; adjusted sub-hazard ratios ranged from 1.7 (for patients with stage 5 cirrhosis and HCC vs those without HCC) to 5.8 (for patients with stage 1 cirrhosis with HCC those without HCC). Medicaid beneficiaries with HCC were also more likely to be placed on the transplant waitlist, compared to patients with decompensated cirrhosis, with a sub-hazard ratio of 2.34 (95% CI, 2.20-2.49). Local organ supply and waitlist-level demand were not associated with placement on the waitlist.
CONCLUSIONS:
In an analysis of US healthcare databases, we found patients with HCC to be more likely to be placed on liver transplant waitlists than patients with decompensated cirrhosis. Previously reported reductions in access to transplant care for waitlisted patients with decompensated cirrhosis underestimate the magnitude of this difference.