Evaluating Factors Impacting Health Disparities in Liver Transplant

Posters review how a patient’s neighborhood impacts access to the liver transplant waitlist and how Medicaid expansion improved waitlist mortality.

Disparities in liver transplantation have been well documented, but 2 new posters presented at The Liver Meeting, held by the American Association for the Study of Liver Diseases, assessed the role of neighborhood-level factors and Medicaid expansion.

In the first poster, the researchers evaluated the relationship between the patient’s neighborhood and liver transplant evaluation.1 In a single-center retrospective cohort study, they linked electronic health record data with the Area Deprivation Index (ADI), which ranks census block groups from least disadvantaged to most disadvantaged using 17 neighborhood-based measures in the American Community Survey.

Adults referred to a transplant center for live transplant were evaluated from August 1, 2016, to December 31, 2019. The median patient age was 56, and 40.7% were female. Patients were stratified by ADI in 4 groups, and the age and sex were similar across all ADI groups.

They found the most deprived ADI group had a significantly higher proportion of Black patients (51%) compared with the least deprived group (6.8%). The most deprived group also had a higher proportion of liver disease due to hepatocellular carcinoma (17.6%) compared with the least deprived group (9.9%) and viral etiology (19.6% vs 5.6%, respectively).

Only 32% of patients in the total cohort were listed, and the researchers noted that patient neighborhood plays an important role in who is added to the waitlist.

“For the transplant community to address equity, we will need to further elucidate solutions with a multilevel approach,” they concluded.

The second poster assessed the impact of Medicaid expansion under the Affordable Care Act on liver transplant waitlist mortality, as well as the impact on transplant rate by race/ethnicity and Model for End-Stage Liver Disease (MELD) score.2

The authors reviewed data in both expansion and nonexpansion states in the pre-expansion period (2008-2013) and postexpansion (2014-2018) period using the UNOS STAR database. They found Medicaid expansion was associated with improvements in waitlist mortality and resulted in higher waitlist Medicaid rates overall for liver transplant. However, Medicaid expansion was not associated with increased transplant rates.

In addition, Medicaid expansion was associated with a decreased transplant rate from the waitlist in patients with a low MELD score and an increased transplant rate in patients with a high MELD score. The researchers also saw that Medicaid expansion increased the number of Hispanic patients on the waitlist. Black patients were impacted depending on MELD score.

“Widespread public health insurance may improve waitlist mortality and impact the demographic profile of patients undergoing transplantation,” they concluded.


1. Strauss AT, Hamilton JPA, Levin S, et al. Health disparities in liver transplant evaluation by the patient’s neighborhood deprivation. Presented at: The Liver Meeting; November 12-15, 2021; virtual. Poster 635.

s. Wahid N, Lee J, Schpero W, et al. Medicaid expansion under the Affordable Care Act associated with improvements in liver transplant waitlist mortality and differential impacts on racial and ethnic disparities in transplant access. Presented at: The Liver Meeting; November 12-15, 2021; virtual. Poster 648.