Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
Department of Transplantation, University of Toronto, Toronto, ON, Canada.
Ann Surg. 2021 Sep 1;274(3):427-433. doi: 10.1097/SLA.0000000000004994.
During the initial wave of the COVID-19 pandemic, organ transplantation was classified a CMS Tier 3b procedure which should not be postponed. The differential impact of the pandemic on access to liver transplantation was assessed.
Disparities in organ access and transplant outcomes among vulnerable populations have served as obstacles in liver transplantation.
Using UNOS STARfile data, adult waitlisted candidates were identified from March 1, 2020 to November 30, 2020 (n = 21,702 pandemic) and March 1, 2019 to November 30, 2019 (n = 22,797 pre-pandemic), and further categorized and analyzed by time periods: March to May (Period 1), June to August (Period 2), and September to November (Period 3). Comparisons between pandemic and pre-pandemic groups included: Minority status, demographics, diagnosis, MELD, insurance type, and transplant center characteristics. Liver transplant centers (n = 113) were divided into tertiles by volume (small, medium, large) for further analyses. Multivariable logistic regression was fitted to assess odds of transplant. Competing risk regression was used to predict probability of removal from the waitlist due to transplantation or death and sickness. Additional temporal analyses were performed to assess changes in outcomes over the course of the pandemic.
During Period 1 of the pandemic, Minorities showed greater reduction in both listing (-14% vs -12% Whites), and transplant (-15% vs -7% Whites), despite a higher median MELD at transplant (23 vs 20 Whites, P < 0.001). Of candidates with public insurance, Minorities demonstrated an 18.5% decrease in transplants during Period 1 (vs -8% Whites). Although large programs increased transplants during Period 1, accounting for 61.5% of liver transplants versus 53.4% pre-pandemic (P < 0.001), Minorities constituted significantly fewer transplants at these programs during this time period (27.7% pandemic vs 31.7% pre-pandemic, P = 0.04). Although improvements in disparities in candidate listings, removals, and transplants were observed during Periods 2 and 3, the adjusted odds ratio of transplant for Minorities was 0.89 (95% CI 0.83-0.96, P = 0.001) over the entire pandemic period.
COVID-19's effect on access to liver transplantation has been ubiquitous. However, Minorities, especially those with public insurance, have been disproportionately affected. Importantly, despite the uncertainty and challenges, our systems have remarkable resiliency, as demonstrated by the temporal improvements observed during Periods 2 and 3. As the pandemic persists, and the aftermath ensues, health care systems must consciously strive to identify and equitably serve vulnerable populations.
在 COVID-19 大流行的初始阶段，器官移植被归类为 CMS 第 3b 层程序，不应推迟。评估大流行对获得肝移植的不同影响。
在肝脏移植中，弱势群体获得器官和移植结果的差异一直是障碍。
使用 UNOS STARfile 数据，从 2020 年 3 月 1 日至 11 月 30 日（n = 21702 大流行）和 2019 年 3 月 1 日至 11 月 30 日（n = 22797 大流行前）确定成年候补候选人，并进一步按时间段进行分类和分析：3 月至 5 月（第 1 期）、6 月至 8 月（第 2 期）和 9 月至 11 月（第 3 期）。大流行前组与大流行组的比较包括：少数民族身份、人口统计学、诊断、MELD、保险类型和移植中心特征。将 113 个肝移植中心按数量（小、中、大）分为三部分进行进一步分析。拟合多变量逻辑回归以评估移植的可能性。使用竞争风险回归来预测因移植或死亡和疾病而从候补名单中移除的概率。进行了额外的时间分析，以评估大流行过程中结果的变化。
在大流行的第 1 期，尽管移植时的中位 MELD 较高（白人 23 分，白人 20 分，P <0.001），但少数族裔在名单上的减少（白人减少 14%，黑人减少 12%）和移植（白人减少 15%，黑人减少 7%）都更大。在有公共保险的候选人中，第 1 期的移植减少了 18.5%（白人减少 8%）。尽管大型项目在第 1 期增加了移植，但占肝移植的 61.5%，而大流行前为 53.4%（P <0.001），但这段时间这些项目中的少数族裔移植明显减少（大流行时为 27.7%，大流行前为 31.7%，P = 0.04）。尽管在第 2 期和第 3 期观察到候选人名单、移除和移植的差距有所改善，但在整个大流行期间，少数族裔的移植调整比值比为 0.89（95%CI 0.83-0.96，P = 0.001）。
COVID-19 对获得肝移植的影响是普遍存在的。然而，少数族裔，尤其是那些有公共保险的人，受到了不成比例的影响。重要的是，尽管存在不确定性和挑战，但我们的系统具有很强的弹性，这从第 2 期和第 3 期观察到的时间改善中可以看出。随着大流行的持续和后续影响，医疗保健系统必须有意识地努力识别和公平地为弱势群体服务。
