Ethnicity and Insurance-Specific Disparities in the Model for End-Stage Liver Disease Score at Time of Liver Transplant Waitlist Registration and its Impact on Mortality

Ann Robinson; Grishma Hirode; Robert J Wong

doi:10.1016/j.jceh.2020.07.011

Ethnicity and Insurance-Specific Disparities in the Model for End-Stage Liver Disease Score at Time of Liver Transplant Waitlist Registration and its Impact on Mortality

J Clin Exp Hepatol. 2021 Mar-Apr;11(2):188-194. doi: 10.1016/j.jceh.2020.07.011. Epub 2020 Aug 8.

Authors

Ann Robinson¹, Grishma Hirode², Robert J Wong^{3

4}

Affiliations

¹ Department of Medicine, Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA.
² Toronto Centre for Liver Disease, University Health Network, Toronto General Hospital, University of Toronto, Canada.
³ Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
⁴ Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA.

Abstract

Background and aims: Disparities in timely referral to liver transplantation (LT) evaluation persist. We aim to examine race/ethnicity and insurance-specific differences in the Model for End-Stage Liver Disease (MELD) score at time of waitlist (WL) registration and its impact on WL survival.

Methods: We retrospectively evaluated U.S. adults listed for LT using 2005-2018 United Network for Organ Sharing LT registry. Multiple linear regression methods examined factors associated with MELD at listing, and Fine-Gray competing risks regression were used to analyze WL mortality.

Results: Among 144,163 WL registrants (median age = 56 years, 65.3% male, 56.4% private insurance, 23.3% Medicare, 15.7% Medicaid), mean WL MELD at listing was higher in African Americans versus non-Hispanic whites (2.57 points higher, 95%CI: 2.40-2.74, P < 0.001). Compared with patients with private insurance, adjusted mean WL MELD was higher among those with no insurance, Medicare, or Medicaid (P < 0.001 for all). After correcting for differences in MELD at listing, Asians had lower risk of WL death versus non-Hispanic whites (subhazard ratio (SHR): 0.92, 95% CI: 0.86-1.00, P = 0.04), but no difference was observed in African Americans or Hispanics. Compared with patients with private insurance, higher risk of WL death was observed in patients with no insurance (SHR: 1.33, 95%CI: 1.14-1.56, P < 0.001), Medicare (SHR: 1.20, 95%CI: 1.16-1.25, P < 0.001), or Medicaid (SHR: 1.22, 95%CI: 1.17-1.27, P < 0.001).

Conclusion: Higher MELD scores at listing among African Americans did not translate into increased WL mortality. Patients with Medicare, Medicaid, or uninsured had significantly higher WL mortality than privately insured patients, even after correcting for disparities in MELD scores at listing.

Keywords: BMI, body mass index; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HR, hazards ratio; LT, liver transplantation; MELD, Model for End-Stage Liver Disease; NASH, nonalcoholic steatohepatitis; OPTN, Organ Procurement and Transplantation Network; UNOS, United Network for Organ Sharing; UNOS/OPTN; WL, waitlist; insurance; liver transplantation; survival; waitlist mortality.