Abstract

Background: Due to socioeconomic and healthcare access challenges, safety-net patients with liver disease face substantial disadvantages. Little is known about which factors – including psychosocial factors – impact listing for liver transplantation (LT) among the safety-net population.

Methods: This was a multi-site retrospective study of adult patients who received outpatient hepatology care and were referred for LT between 2016 and 2022 from LA General Medical Center, which is one of the largest municipal safety-net hospitals and serves as the referring center to two transplant centers (Keck USC or UCLA). Demographics, clinical data, and LT evaluation outcomes were collected from the medical record. Among those who completed LT evaluation, detailed psychosocial data from the initial LT social work assessment were collected. Univariate and multivariate analyses were performed to determine clinical and psychosocial predictors of LT listing.

Results: Out of 318 referred safety-net patients, 238 were evaluated for LT, with 233 having received a listing decision (135 listed, 98 declined). 80.0% had Medi-Cal insurance, 34.3% were primarily English-speaking, 53.1% were unemployed, and 44.3% had less than a high school education. Patients were similar in age, race/ethnicity, sex, disease etiology, and clinical decompensation by listing status. Per univariate analysis, listed patients were more likely to be legal residents than undocumented, live in a house, have ample social support, be married, be foreign-born, and have NASH. They were less likely to have transportation and financial barriers, unstable housing, and limited sobriety. After adjusting for age, evaluation site, and race/ethnicity, multivariable analysis identified legal status (OR 0.37, 95% CI 0.14-0.96), social support (OR 4.21, 95% CI 1.69-10.51), and living in a house (OR 3.25, 95% CI 1.58-6.68) as independent predictors of listing (Table). There was a non-significant trend towards higher odds of listing if foreign-born and no transportation barriers. Among 98 declined patients, the most common reasons for denial were lack of social support (23), being too early for LT (22), limited sobriety (19), HCC tumor burden (15), adherence concerns (14), and comorbidity (11).

Conclusion: Among safety-net patients, psychosocial rather than clinical factors were predictive of LT listing. Targeted efforts to modify these factors may mitigate disparities in the LT listing process for underserved populations.