Examining the Impact of the COVID-19 Pandemic on Racial and Ethnic Disparities in Access to Liver Transplantation: A Retrospective Analysis

Background:

Racial and ethnic minorities often experience delays in accessing liver transplantation (LT) compared to their white counterparts, which can result in and contribute to worse post-transplant outcomes (Wahid, 2021). The COVID-19 pandemic has exacerbated pre-existing disparities with minorities experiencing poorer health outcomes (Lopez, 2021). This period has also seen immense socio-cultural flux, with social movements such as the George Floyd protests and the Stop Asian Hate movement drawing attention to issues of diversity, equity, and inclusion.

We investigated the role of race and ethnicity in access to LT, with a specific focus on changes between pre- and post-pandemic periods.


Methods:

We conducted an IRB-approved single-center, retrospective analysis utilizing data of adult patients referred for LT evaluation to a New England transplant center in 2019 (pre-pandemic) and 2022 (post-pandemic). Data included demographics, medical and social history, dates of referral, evaluation and listing, and reasons for refusal/deferral. Primary outcome analyzed was ethnic/racial differences [non-Hispanic whites (NHW) and other races/ethnicities (OTH)] in time from referral to initial evaluation (TRE), referral to listing (TRW) and evaluation to listing (TEW). T-test and Chi-square statistical tests were used as appropriate.

Results (preliminary):

In 2019, 273 patients were referred, 30% were waitlisted (32% NHW, 25% OTH). In 2022, 287 patients were referred, 10.4% were waitlisted (11% NHW, 9% OTH), indicating an overall reduction in the rate of listing.

When comparing NHW and OTH, there were no statistically significant differences in TRE, TRW and TEW seen in either year. In 2022, when compared to 2019, NHW had statistically significant reduction in TRW (117.5 vs 231.7 days (d); p< 0.001) and TEW (93.05 vs 199.39 d; p< 0.001). This reduction in TRW was not significant in OTH (156.1 vs 248.4 d; p=0.06). TRE also decreased for both NHW (32.8 vs 42.9 d; p=0.08) and OTH (38.4 vs 57.7 d; p=.11) without reaching statistical significance when comparing 2022 versus 2019. Our complete analysis will investigate the significance of psychiatric factors in the decrease of listing rate, TRW, TEW, TRW pre- and post-COVID-19 pandemic.

Discussion:

Our findings suggest that at our center NHW patients benefited more from improved accessibility times to LT post-COVID-19 pandemic than OTH candidates. We found a significant decrease in the rate of LT listing, which could be caused by stricter screening (e.g., implementation of Phosphatidylethanol testing to assess active alcohol use), improved administrative efficiency, or decreased ability to complete medical work-up. These findings also raise questions about potential disparities in access to healthcare for minorities.

Implications:

Our study highlights the need for continued attention to issues of inequity in the context of LT. While there may be increased efficiency of the transplant program, there are still disparities in access to care that need to be addressed to ensure equitable outcomes for all patients.

References:

Wahid NA, Rosenblatt R, Brown RS Jr. A Review of the Current State of Liver Transplantation Disparities. Liver Transpl.2021 Feb;27(3):434-443.

Lopez L, Hart LH, Katz MH. Racial and Ethnic Health Disparities Related to COVID-19. JAMA.2021;325(8):719–720.