The Racial Gap in Liver Transplant Access Widened During the Pandemic

Minorities in the United States, especially those with public insurance, experienced a sudden drop in access to liver transplants in the early months of the pandemic, with a twofold decrease in access to transplant surgery compared with whites.

Throughout the pandemic, organ transplantation was classified as a CMS (Centers for Medicare & Medicaid Services) Tier 3b procedure, which should not be postponed.

But an analysis showed that minorities were less likely to be listed for transplant and more likely to be removed from the waitlist in the first three months of the pandemic. In this study, minorities included people who identified as African American, Hispanic, Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, or multiracial.

“We have to be cognizant that when stress hits a system, existing disparities in access to care can be exacerbated, placing vulnerable populations at risk,” said lead author Parsia Vagefi, MD, the chief of surgical transplantation at UT Southwestern Medical Center, in Dallas.

Transplant rates among minorities rebounded by fall 2020, the analysis showed.

Investigators used UNOS STAR file data to compare liver transplants in 2019 and 2020, looking for differences based on minority status, demographics, diagnosis, Model for End-stage Liver Disease (MELD) score, insurance type and transplant center characteristics.

Between March and May 2020, the number of minority patients added to the waitlist for a transplant dropped 14%, compared with 12% for whites. Minorities underwent 15% less transplants than in 2019, double the rate of decrease among white patients. Of minority patients who underwent transplantation, they had a higher median MELD score: 23 versus 20 for whites (P<0.001). The likelihood of transplant in minorities was further reduced when compounded with public insurance status, high MELD scores (>20) and large transplant centers.

Minorities were removed from the waitlist because of death or being too sick more often than wait-listed white patients. They were far more likely to be inactivated on the waitlist because of a COVID-19 precaution; this affected 8.3% of minorities on the waitlist compared with 5.5% for white patients (P<0.001).

Among patients who were publicly insured, minorities experienced the largest drop in access to transplants, down 18.5% over 2019, compared with 8% for whites.

Privately insured minority and white patients had similar decreases in rates of liver transplant at the start of the pandemic. By fall 2020, liver transplants among privately insured patients were on the upswing.

Despite the upheaval of 2020, large transplant programs increased the number of transplants over the year, but minority patients accounted for fewer transplants at these programs—down to 27.7% from 31.7% before the pandemic.

This article is from the July 2021 print issue.