Regional Social Vulnerability is Associated with Geographic Disparity in Waitlist Outcomes for Patients with Non-HCC MELD Exceptions in the United States

Abstract

Background: This study was undertaken to evaluate the role of regional social vulnerability in geographic disparity for patients listed for liver transplant with non-HCC MELD exceptions. Methods: Adults listed at a single center for a first time liver only transplant without HCC after June 18, 2013 in the SRTR database as of March 2021 were examined. Candidates were mapped to hospital referral regions (HRRs). Adjusted likelihood of mortality and liver transplant were modeled. Advantaged HRRs were defined as those where exception patients were more likely to be transplanted, yet no more likely to die in adjusted analysis. The Centers for Disease Control’s Social Vulnerability Index (SVI) was used as the measure for community health. Higher SVIs indicate poorer community health. Results: There were 49,494 candidates in the cohort, of whom 4,337 (8.8%) had MELD exceptions. Among continental US HRRs, 27.3% (n=78) were identified as advantaged. The mean SVI of advantaged HRRs was 0.42 vs. 0.53 in non-advantaged HRRs (P=0.002), indicating better community health in these areas. Only 25.3% of advantaged HRRs were in spatial clusters of high SVI vs. 40.7% of non-advantaged HRRs, while 44.6% of advantaged HRRs were in spatial clusters of low SVI vs.38.0% of non-advantaged HRRs (P=0.037). Conclusion: Advantage for non-HCC MELD exception patients is associated with lower social vulnerability on a population level. These findings suggest assigning similar waitlist priority to all non-HCC exception candidates without considering geographic differences in social determinants of health may actually exacerbate rather than ameliorate disparity.