Identifying determinants of access to the early steps of liver transplant in the Southeast

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Project Summary / Abstract Cirrhosis is a major public health problem in the United States, affecting approximately 4.5 million people with increased prevalence among persons living in poverty and insured by Medicaid. Decompensated cirrhosis, also called end-stage liver disease (ESLD), occurs when patients begin to experience major complications of cirrhosis, including ascites, variceal bleeding, and encephalopathy, with ~200,000 incident cases and 50,000 deaths in the U.S. each year. For patients with ESLD, liver transplant is the only curative treatment option. In 2021, there were approximately 9,000 liver transplants in the U.S. Transplantation is a complex, multistep process that begins at ESLD diagnosis and requires referral to a highly specialized transplant center. This is followed by completion of an intense, holistic medical and psychosocial evaluation process, and, if selected, being placed on the national waiting list for a deceased donor liver. Once patients are waitlisted, they are surveilled by the United Network for Organ Sharing (UNOS), which monitors equity in access to transplantation for patients on the deceased donor waiting list in addition to post-transplant outcomes. While access to liver transplant once waitlisted is relatively equitable, there are racial, socioeconomic, and geographic disparities in waitlisting. Because of data limitations, potential disparities in earlier steps to liver transplant (i.e. referral and evaluation) that may lead to observed differences in waitlisting remain unknown. Using data from two liver transplant centers serving a 108-county region in Georgia, Alabama, Tennessee and South Carolina served by Emory and Piedmont (Atlanta catchment area), combined with patient and provider interviews, the proposed application will identify key factors that influence access to liver transplant referral and evaluation for ESLD patients in the Southeast. This work will inform a future R01 application to develop and test an intervention to increase equity in access to the early steps of liver transplant in this region. The mentoring team, Drs. Rachel Patzer (primary mentor), Dio Kavalieratos (co-mentor) and Raymond Lynch (co-mentor), represent a combined wealth of expertise in transplant epidemiology, clinical liver transplantation, health services research, and qualitative and mixed methods research. Through the training provided by this K01, Dr. Ross-Driscoll will obtain additional knowledge of clinical aspects of liver transplantation, and methodological skills in spatial epidemiology, qualitative research and intervention development. The combination of research and training support provided by this K01 award will allow her to build on her previous experience in liver transplantation, epidemiology, and health services research to become an expert in the field of liver transplant access.