Access to early liver transplantation is adversely impacted by social determinants of health: A retrospective cohort study

Early liver transplant (ELT) is the practice of liver transplant for those with severe alcohol-associated hepatitis or acute on chronic alcohol-associated liver disease, without requiring any minimum pre-transplant abstinence period. It is an increasingly adopted practice for alcohol-associated liver disease (ALD) capable of providing excellent outcomes, but there are concerns regarding equity in access to ELT. Our objectives were (1) to quantify the association between social determinants of health (SDoH) and progression from referral to listing, and (2) to identify geographic disparities in referrals for ELT. We included 501 ELT candidates and a comparison population of 165 standard liver transplantation (SLT) candidates referred from 2017 to 2023. Multivariable regression quantified the association between individual-level and neighborhood-level SDoH and progression from referral to listing, adjusting for sociodemographic characteristics and MELD. Negative binomial regression quantified the association between neighborhood-level SDoH and the number of ELT referrals within 150 Nmi of our institution, adjusting for relevant geographic confounders. ELT candidates with Medicaid insurance were less likely to progress from referral to evaluation than candidates with private insurance (RR 0.69, 95% CI 0.56-0.85). ELT candidates from census tracts with a high Social Vulnerability Index (SVI) were less likely to progress from evaluation to listing than candidates from low SVI census tracts in Modified Poisson Regression (RR 0.64, 95% CI 0.46-0.88), but not in Cox regression (HR 0.67, 95% CI 0.41-1.09). These findings were not significant among SLT candidates. High SVI census tracts were less likely to have individuals referred for ALD compared to tracts with low SVI (incidence rate ratio [IRR] 0.53, 95% CI 0.42-0.66). Both individual-level and neighborhood-level SDoH are important factors that ultimately influence who is eligible for transplant.