Study Finds Biases in Liver Transplant System


SAN FRANCISCO — Despite the introduction in 2001 of an objective scoring system for liver disease, African Americans and Medicaid recipients remain less likely than other groups to receive the special exemptions that can shorten the wait for a liver transplant, according to a poster presentation at the American Transplant Congress.

Compared with whites, African Americans are 22% less likely to receive a special case exemption (SCE). And compared with patients with private insurance, those receiving Medicaid are 38% less likely to receive an SCE, according to the study by Dr. Curtis K. Argo and colleagues at the University of Virginia, Charlottesville.

“Most worrisome,” wrote the investigators, is the fact that self-payers were 64% more likely than those with private insurance to receive an SCE. “[This] implies that more SCEs are awarded to the wealthiest candidates.” The investigators noted that 37% of self-pay patients are foreign nationals.

The study involved 66,153 liver transplant candidates who were listed on the United Network for Organ Sharing waiting list from the inception of the Model for End-Stage Liver Disease (MELD) scoring system in 2001 through April 2006.

Of those, 28% had received a transplant, 50% remained on the waiting list, and 22% had died or had been removed from the waiting list for other reasons.

Special case exemptions are allowed for certain genetic or physiologic conditions such as hepatopulmonary syndrome or familial amyloidosis, or for certain symptom-based reasons such as refractory ascites, refractory encephalopathy, or refractory pruritus.

In all, 7.9% of the transplant recipients received an SCE.

Other research has determined that receiving an SCE decreases the likelihood that a patient will die on the waiting list by 71%.

After adjustment for MELD score, region, ABO blood group, degree of encephalopathy, degree of ascites, ethnic group, gender, year of listing, age at listing, and primary insurance payer, an African American patient's odds ratio of receiving an SCE was 0.78, compared with that of a white patient, a statistically significant difference.

There were no significant differences between white and Hispanics or members of other ethnic groups.

Compared with patients covered by private insurance, a Medicaid patient's odds ratio of receiving an SCE was 0.62, and self-payers had an odds ratio of 1.64, with both differences being statistically significant.

There were no significant differences between patients with private insurance and those on Medicare or those receiving their insurance from another government agency.

The investigators concluded, “These findings strongly support additional close scrutiny of current SCE award procedures and insinuate that SCE awards criteria require significant revision due to these biases.”

The congress was cosponsored by The American Society of Transplant Surgeons and the American Society of Tranplantation.

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