At the earliest: a Hub and Spoke referral and referral-back pilot project increases access to liver transplantation and ensures good long-term care

Liver transplantation (LT) represents an effective therapeutic option for patients with end-stage liver disease and hepatocellular carcinoma. However, barriers to access LT programs still exist for many patients, including distance from transplant centers and delays in referral. Furthermore, long-term care is required also in stable LT recipients. This pilot study aims to evaluate the characteristics and outcomes of patients with end-stage liver disease referred to Padua University Hospital following the implementation of a structured referral program with Trento Hospital. Furthermore, the study assesses the outcomes of LT recipients who were referred back and continued follow-up care at the Spoke Center. After an internal work reorganization at the Spoke Center to improve care for patients with liver disease, we designed this prospective pilot study based on a structured referral and referral-back program for managing patients before and after LT. Accordingly, all inpatients potentially eligible for LT were transferred from the Gastroenterology Unit at Trento Hospital to the Multivisceral Transplant Unit at Padua University Hospital between 2020-2023. Similarly, stable LT recipients were referred back to the Spoke Center for management of long-term follow-up. During the study period, 27 adult inpatients (59% male; median age 50 [42-51] years) deemed eligible for LT were consecutively referred from Trento to Padua. The median [IQR] MELD score at the time of referral was 26 [23-30], and the length of stay at the LT Center was 21 [18-23] days. At the end of follow-up, 6 (22%) patients underwent LT, while the transplant-free survival rate was 37%. During the same period, 27 stable adult LT recipients (55% male; median age at referral back 56 years; median time since LT 9 years) living near Trento were referred back to the Spoke Center. During the follow-up, n.19 (70%) patients experienced at least one medical complication (40% liver-related), the majority of these being managed at the Spoke Center. LT recipient satisfaction of this way of care Center was high. A structured Hub and Spoke collaboration increase access to LT, making it more equitable, and improves the management of stable LT recipients closer to home.