Multilevel determinants of racial disparities in outcomes among liver transplant recipients in the United States

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Project Summary Liver transplantation is the only curative treatment for end-stage liver disease (ESLD), which kills approximately 50,000 people in the United States each year. There are substantial and persistent racial disparities in liver transplant outcomes. Black patients have lower graft function, worse graft survival, and worse overall survival after liver transplantation than do patients of any other race. The association of race, survival, and shorter-term outcomes, such as hospital readmissions, remains unclear for liver transplant recipients. Hospital readmission may represent a potential target for intervention and a marker to identify groups at high risk for poor outcomes while they are accessible to clinicians. The overall goal of this project is to identify determinants of racial disparities in both short-term (hospitalization) and long-term (survival) outcomes among liver transplant recipients. Using national data from the Scientific Registry of Transplant Recipients (SRTR), a population-based registry of transplant recipients, I will conduct a retrospective cohort study of patients who received a liver transplant in the United States from 2003 to 2017. I will use hierarchical survival analysis to determine whether the association of race with post-transplant survival differs by characteristics of the transplant center. I will then use multivariable log-binomial regression to estimate the association between patient race and risk of hospital readmission within six months of transplant, and conduct a mediation analysis to determine whether racial disparities in survival after transplant are mediated through hospital readmission. The SRTR documents whether recipients are hospitalized in the six months following transplant. However, there is no information collected on the timing of hospitalization within that interval, reasons for hospitalization, or the overall burden of hospitalization; these characteristics provide important insight into the underlying mechanisms of hospitalization. I will use more granular data from the Emory Transplant Center, one of the largest transplant centers in the nation, to identify racial disparities in these novel outcomes. Upon completion of these aims, I will have identified characteristics of transplant centers suitable for intervention to reduce racial disparities in outcomes, quantified the potential impact of differences in hospital readmission on disparities in survival, and identified differences in hospitalization characteristics by race. Each of these objectives contributes to my long-term goal of informing future multilevel interventions to improve patient care and reduce inequity among liver transplant recipients.