title: Subjective parameters markedly limit the referral of transplantation candidates to liver transplant centres.
abstract: OBJECTIVE
  Equality of access to organ transplantation is a mandatory public health requirement. Referral from a local to a university hospital and then registration on the national waiting list are the two key steps enabling access to liver transplantation (LT). Although the latter procedure is well defined using the Model for End-stage Liver Disease score that improves equality of access, the former is mostly reliant on the practices of referring physicians. The aim of this study was to clarify the factors determining this initial step.
  
  
  METHODS
  This observational study included consecutive inpatients with cirrhosis of whatever origin in a cohort constituted between 2003 and 2008, using medical records and structured questionnaires concerning patient characteristics and the opinions of hospital clinicians. Candidates for LT were defined in line with these opinions.
  
  
  RESULTS
  Four hundred and thirty-three patients, mostly affected by alcoholic cirrhosis, were included, 21.0% of whom were considered to be candidates for LT. Factors independently associated with their candidature were: physician empathy [odds ratio (OR) = 10.8; 95% CI: 4.0-29.5], adherence to treatment (OR = 16.6; 95% CI: 3.7-75.2), geographical area (OR = 6.8; 95% CI: 2.2-21.3) and the patient's physiological age (OR = 2.3; 95% CI: 1.1-4.7).
  
  
  CONCLUSIONS
  Several subjective markers restrict the referral of patients from local hospitals to liver transplant centres. Their advancement to this second step is thus markedly weakened by initial subjectivity. The development of objective guidelines for local hospital physicians to assist them with their initial decision-making on LT is now necessary.
authors.affiliation: Public Health Unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, Paris, France.|Department of Public Health, Faculty of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France.|Research Unit (INSERM U1153) Methods Team, Methods of Therapeutic Evaluation of Chronic Diseases, Research Center Epidemiology and Biostatistics, Sorbonne Paris Cité, Paris, France.
authors.forename: Gwenaëlle
authors.initials: G
authors.lastname: Vidal-Trécan
authors.affiliation: Public Health Unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, Paris, France.
authors.forename: Victoria
authors.initials: V
authors.lastname: Kone
authors.affiliation: Hepatogastroenterology Department, CHG du Mans, Le Mans, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Pilette
authors.affiliation: Hepatogastroenterology Department, CHU de Brest, Brest, France.
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Nousbaum
authors.affiliation: Hepatogastroenterology Department, CHG de Versailles, Versailles, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Doll
authors.affiliation: Hepatogastroenterology Department, CHU Kremlin Bicètre, Kremlin Bicètre, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Buffet
authors.affiliation: Hepatogastroenterology Department, CHG de Poissy, Poissy, France.
authors.forename: Claude
authors.initials: C
authors.lastname: Eugene
authors.affiliation: Centre de Reference en Addictologie, Pitie-Salpetriere Hospital, AP-HP, Paris Descartes University, Paris, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Podevin
authors.affiliation: Hepatogastroenterology Department, CHG de Bagnoles sur Cèze, Bagnoles sur Cèze, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Boutet
authors.affiliation: Hepatogastroenterology Department, CHG de Carcassonne, Carcassonne, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Puyeo
authors.affiliation: Centre de Transplantation Hepatique, Pitie-Salpetriere Hospital, AP-HP, Paris Descartes University, Paris, France.
authors.forename: Filomena
authors.initials: F
authors.lastname: Conti
authors.affiliation: Centre de Transplantation Hepatique, Pitie-Salpetriere Hospital, AP-HP, Paris Descartes University, Paris, France.
authors.forename: Yvon
authors.initials: Y
authors.lastname: Calmus
mesh_terms: D000367:Age Factors; D000368:Aged; D001291:Attitude of Health Personnel; D002391:Catchment Area, Health; D003661:Decision Support Techniques; D004645:Empathy; D005260:Female; D005602:France; D006297:Health Services Accessibility / Q000639:trends*; D054625:Healthcare Disparities / Q000639:trends*; D006801:Humans; D008104:Liver Cirrhosis, Alcoholic / Q000175:diagnosis / Q000523:psychology / Q000601:surgery*; D016031:Liver Transplantation / Q000639:trends*; D016015:Logistic Models; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010349:Patient Compliance; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011237:Predictive Value of Tests; D017064:Process Assessment, Health Care / Q000639:trends*; D012017:Referral and Consultation / Q000639:trends*; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013997:Time Factors
keywords: alcoholic; health service accessibility; liver cirrhosis; liver transplantation; physician-patient relations