Use of Population-based Data to Demonstrate How Waitlist-based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care

D S Goldberg; B French; G Sahota; A E Wallace; J D Lewis; S D Halpern

doi:10.1111/ajt.13820

Use of Population-based Data to Demonstrate How Waitlist-based Metrics Overestimate Geographic Disparities in Access to Liver Transplant Care

Am J Transplant. 2016 Oct;16(10):2903-2911. doi: 10.1111/ajt.13820. Epub 2016 May 17.

Authors

D S Goldberg^{1

2

3}, B French^{2

3}, G Sahota⁴, A E Wallace⁴, J D Lewis^{1

2

3}, S D Halpern^{2

3

5}

Affiliations

¹ Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.
² Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
⁴ HealthCore, Inc., Wilmington, DE.
⁵ Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA.

Abstract

Liver allocation policies are evaluated by how they impact waitlisted patients, without considering broader outcomes for all patients with end-stage liver disease (ESLD) not on the waitlist. We conducted a retrospective cohort study using two nationally representative databases: HealthCore (2006-2014) and five-state Medicaid (California, Florida, New York, Ohio and Pennsylvania; 2002-2009). United Network for Organ Sharing (UNOS) linkages enabled ascertainment of waitlist- and transplant-related outcomes. We included patients aged 18-75 with ESLD (decompensated cirrhosis or hepatocellular carcinoma) using validated International Classification of Diseases, Ninth Revision (ICD-9)-based algorithms. Among 16 824 ESLD HealthCore patients, 3-year incidences of waitlisting and transplantation were 15.8% (95% confidence interval [CI] : 15.0-16.6%) and 8.1% (7.5-8.8%), respectively. Among 67 706 ESLD Medicaid patients, 3-year incidences of waitlisting and transplantation were 10.0% (9.7-10.4%) and 6.7% (6.5-7.0%), respectively. In HealthCore, the absolute ranges in states' waitlist mortality and transplant rates were larger than corresponding ranges among all ESLD patients (waitlist mortality: 13.6-38.5%, ESLD 3-year mortality: 48.9-62.0%; waitlist transplant rates: 36.3-72.7%, ESLD transplant rates: 4.8-13.4%). States' waitlist mortality and ESLD population mortality were not positively correlated: ρ = -0.06, p-value = 0.83 (HealthCore); ρ = -0.87, p-value = 0.05 (Medicaid). Waitlist and ESLD transplant rates were weakly positively correlated in Medicaid (ρ = 0.36, p-value = 0.55) but were positively correlated in HealthCore (ρ = 0.73, p-value = 0.001). Compared to population-based metrics, waitlist-based metrics overestimate geographic disparities in access to liver transplantation.

Keywords: disparities; epidemiology; ethics and public policy; health services and outcomes research; liver transplantation/hepatology; organ allocation; organ procurement and allocation.

Publication types

Research Support, U.S. Gov't, P.H.S.
Research Support, N.I.H., Extramural

MeSH terms

Datasets as Topic
End Stage Liver Disease / epidemiology
End Stage Liver Disease / surgery*
Female
Follow-Up Studies
Geography
Health Services Accessibility / statistics & numerical data*
Healthcare Disparities / statistics & numerical data*
Humans
International Classification of Diseases
Liver Transplantation*
Male
Middle Aged
Prognosis
Retrospective Studies
Tissue and Organ Procurement*
United States / epidemiology
Waiting Lists*

Grants and funding

K08 DK098272/DK/NIDDK NIH HHS/United States