The influence of equitable access policies and socioeconomic factors on post-liver transplant survival

BACKGROUND: Survival following liver transplant (LT) is influenced by a variety of factors, including donor risk factors and recipient disease burden and co-morbidities. It is difficult to separate these effects from those of socioeconomic factors, such as income or insurance. The United Network for Organ Sharing (UNOS) created equitable access policies, such as Share 35, to ensure that organs are distributed to individuals with greatest medical need; however, the effect of Share 35 on disparities in post-LT survival is not clear. This study aimed to (1) characterize associations between post-transplant survival and race and ethnicity, income, insurance, and citizenship status, when adjusted for other clinical and demographic factors that may influence survival, and (2) determine if the direction of associations changed after Share 35. METHODS: A retrospective, cohort study of adult LT recipients (n = 83,254) from the UNOS database from 2005 to 2019 was conducted. Kaplan-Meier survival graphs and stepwise multivariate cox-regression analyses were performed to characterize the effects of socioeconomic status on post-LT survival, adjusted for recipient and donor characteristics, across the time period and after Share 35. FINDINGS: Male sex (HR: 0.93 (95% CI: 0.90–0.96)), private insurance (0.91 (0.88–0.94)), income (0.82 (0.79–0.85)), U.S. citizenship, and Asian (0.81 (0.75–0.88)) or Hispanic (0.82 (0.79–0.86)) race and ethnicity were associated with higher post-transplant survival, after adjustment for clinical and demographic factors (Table 3). These associations were found across the entire time period studied and many persisted after the implementation of Share 35 in 2013 (Table 3; male sex (0.84 (0.79–0.90)), private insurance (0.94 (0.89–1.00)), income (0.82 (0.77–0.89)), and Asian (0.87 (0.73–1.02)) or Hispanic (0.88 (0.81–0.96)) race and ethnicity). INTERPRETATION: Recipients’ socioeconomic factors at time of transplant may impact long-term post-transplant survival, and a single policy may not significantly alter these structural health inequalities. FUNDING: None