Social Determinants Are Important Barriers to Completion of the Liver Transplant Pathway and Are Associated with Waitlisting and Mortality in Hepatocellular Carcinoma.

BACKGROUND

Hepatocellular carcinoma (HCC) is a serious consequence of chronic liver disease, with liver transplantation (LT) as the most durable curative option. However, significant disparities in access persist. Further, there is a lack of data on social determinants of health (SDOH) and disease-related barriers to HCC-LT pathway completion.

METHODS

This retrospective cohort study included adults referred to a single center for LT with HCC from 2017 to 2021. SDOH exposures included race, ethnicity, gender, insurance type, area deprivation index (ADI), and marital status. Data from transplant database notes, including open-text fields documenting reasons for evaluation discontinuation, were used to identify and categorize reasons for failure to complete six predefined steps in the HCC-LT pathway. Multivariable logistic regression and competing risk analysis evaluated factors associated with waitlisting and survival.

RESULTS

Among 495 HCC patients referred for LT, 8.7% were Black and 57.2% were insured by Medicaid, with a mean ADI of 69.0 (± 21.1). Disease-related barriers (39.0%) and social barriers (35.6%) were common reasons for failing to complete the LT pathway. Public insurance (aOR 0.65, 95% CI 0.44-0.95) and being unmarried (aOR 0.60, 95% CI 0.40-0.88) were independently associated with a lower odd of waitlisting, and high ADI (aHR 1.01, 95% CI 1.00-1.02) was associated with mortality.

CONCLUSIONS

Insurance type and marital status were associated with a failure to waitlist and ADI with survival. The SDOH were important barriers to completing the HCC-LT pathway. Targeted interventions are needed to support at-risk patients through the HCC-LT process.