In a retrospective cohort study of adults referred for liver transplant to the Indiana University Academic Medical Center from 2011 through 2018, it was concluded that patients from high poverty neighborhoods are at risk of failing to be waitlisted and death during the transplant evaluation. Lauren Nephew, MD, assistant professor of medicine for the Division of Gastroenterology and Hepatology at IU School of Medicine, was the senior author of this study, recently published in Liver Transplantation.
Nephew said they wanted to look back at experiences over a long period of time, but not so far back that program changes could impact the integrity of study results. They were surprised to learn how important lived environments are to liver transplant outcomes.
“In a multi-variable model that included so many clinical and individual determinants, including the score for end stage liver disease, neighborhood poverty remained independently associated with these outcomes,” said Nephew, who was an Indiana Clinical and Translational Sciences Institute (CTSI) KL2 scholar in 2018. “The strength of the association is eye opening to the impact of the social and structural determinants of health on the lives of our patients.”
The burden of liver disease is high in racial and ethnic minority populations. Liver transplantation is the final step in a complex care cascade, and little is generally known about how race, gender, rural versus urban residence, or neighborhood socio-economic indicators impact a patient’s likelihood of liver transplant waitlisting or risk of death during the evaluation.
“What we found is that the number of Black and Hispanic patients who are referred for liver transplantation was lower than the population in the state and in the Indianapolis metro area,” explained Nephew. “We are the only transplant center in the state of Indiana. This tells us that we are not capturing everyone who needs care.”
There were 3,454 patients referred for liver transplantation during the study period and just over 25 percent of those were waitlisted. There was no difference seen in the proportion of patients from vulnerable populations who progressed to the steps of financial approval or evaluation start.
There were also differences in waitlisting by insurance type: 22.6 percent of Medicaid versus 34.3 percent of those privately insured. On multi-variable analysis, neighborhood poverty was independently associated with waitlisting and death during evaluation.
Nephew said her dream would be to identify patients who come from high-risk neighborhoods around Indiana at the time of referral for tailored evaluation, navigation, case management, and education programs in transplant that could help them more successfully navigate the liver transplantation care cascade. But on a smaller scale, she would like to be able to flag patients in the system and add them to care teams at the time of referral so social workers, coordinators, hepatologists, and providers are aware of who they are and can support them within the current care plan through the evaluation process.
“I think our program and many programs around the country would benefit from a comprehensive liver transplant care access clinic and program for patients with high-risk social determinants of health,” said Nephew. “We could be pioneers in that space, but it certainly would take a significant financial investment.”