title: Racial and ethnic disparities in access to liver transplantation.
abstract: Access to liver transplantation is reportedly inequitable for racial/ethnic minorities, but inadequate adjustments for geography and disease progression preclude any meaningful conclusions. We aimed to evaluate the association between candidate race/ethnicity and liver transplant rates after thorough adjustments for these factors and to determine how uniform racial/ethnic disparities were across Model for End-Stage Liver Disease (MELD) scores. Chronic end-stage liver disease candidates initially wait-listed between February 28, 2002 and February 27, 2007 were identified from Scientific Registry for Transplant Recipients data. The primary outcome was deceased donor liver transplantation (DDLT); the primary exposure covariate was race/ethnicity (white, African American, Hispanic, Asian, and other). Cox regression was used to estimate the covariate-adjusted DDLT rates by race/ethnicity, which were stratified by the donation service area and MELD score. With averaging across all MELD scores, African Americans, Asians, and others had similar adjusted DDLT rates in comparison with whites. However, Hispanics had an 8% lower DDLT rate versus whites [hazard ratio (HR) = 0.92, P = 0.011]. The disparity among Hispanics was concentrated among patients with MELD scores < 20, with HR = 0.84 (P = 0.021) for MELD scores of 6 to 14 and HR = 0.85 (P = 0.009) for MELD scores of 15 to 19. Asians with MELD scores < 15 had a 24% higher DDLT rate with respect to whites (HR = 1.24, P = 0.024). However, Asians with MELD scores of 30 to 40 had a 46% lower DDLT rate (HR = 0.54, P = 0.004). In conclusion, although African Americans did not have significantly different DDLT rates in comparison with similar white candidates, race/ethnicity-based disparities were prominent among subgroups of Hispanic and Asian candidates. By precluding the survival benefit of liver transplantation, this inequity may lead to excess mortality for minority candidates.
authors.affiliation: Division of Transplantation, Department of Surgery, University of Michigan, Ann Arbor, MI 48109-5342, USA. amitmath@med.umich.edu
authors.forename: Amit K
authors.initials: AK
authors.lastname: Mathur
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Schaubel
authors.forename: Qi
authors.initials: Q
authors.lastname: Gong
authors.forename: Mary K
authors.initials: MK
authors.lastname: Guidinger
authors.forename: Robert M
authors.initials: RM
authors.lastname: Merion
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D001213:Asian / Q000706:statistics & numerical data; D002908:Chronic Disease; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities / Q000208:ethnology*; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008107:Liver Diseases / Q000208:ethnology* / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000208:ethnology*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D016016:Proportional Hazards Models; D044469:Racial Groups / Q000706:statistics & numerical data*; D012042:Registries; D012111:Residence Characteristics; D040841:Resource Allocation; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014019:Tissue Donors / Q000600:supply & distribution; D009927:Tissue and Organ Procurement / Q000706:statistics & numerical data; D014481:United States; D014850:Waiting Lists; D044465:White People / Q000706:statistics & numerical data
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