Higher Income Associated With Lower Risk of Liver Disease But Higher Likelihood of Listing for Liver Transplantation.

Abstract

Access to solid organ transplantation varies by gender, race, place of residence, and insurance status. The factors influencing liver transplantation wait list rates are not well understood because there is no registry of patients with end-stage liver disease (ESLD). We therefore assessed the number of patients listed for liver transplantation compared with the incidence of fatal liver disease in 3,220 US counties. County demographic characteristics over 8 years were determined from US Census data. Deaths due to liver disease were defined as death certificates containing an ICD-10 code indicating a liver diagnosis as a cause of death. Wait list data was obtained from the Scientific Registry of Transplant Recipients. 17 covariates, including geographic, demographic, and socioeconomic characteristics, were analyzed for their effect on death and wait list rates. Deaths due to liver disease vary from 0 to 17.7 deaths per 10,000 county population per year (mean 3.0 ± 1.2). Liver death rate increases with age, percent Hispanic and Native American population, and age adjusted death rate, but decrease with increasing income (p<10-16 for all). Although annual wait list registrations vary from 0 to 8 per 10,000 county population (mean 0.3 ± 0.2), wait list rates per liver death fall into a narrower range from 0 to 3 per death (mean 0.1 ± 0.1). Considering only those candidates with listing MELD>15, registrations per liver death range from 0 to 1.5 (mean 0.05 ± 0.06). Wait list rates per liver disease death increase with income and decrease with larger distance to the nearest transplant center (p<10-16 for both), with those two factors accounting for 24% of the observed variability. Much of the county variation in wait list rates per capita is attributable to variation in the incidence of liver disease. Higher income is associated with decreased risk of death from liver disease, as well as with increased chance of being listed for transplantation. Increasing distance to the nearest transplant center also decreases the likelihood of being listed. Listing at any initial MELD score probably reflects access to specialized liver care at transplant centers. Thus, patients in counties with higher listing rates may have better access to such care earlier in their disease course. Counties listing more patients than die of liver disease may achieve this by treating ESLD patients with transplantation.