Liver transplant referrals low at safety-net hospitals

In a study, undocumented citizenship, unstable housing and uninsured status were common among people who did not get referrals for transplant evaluation.

Among people whose liver is failing, the perpetual shortage of donor organs inhibits expectations of a timely, life-saving transplant. New research suggests that these people who initially seek care at safety-net hospitals may face additional obstacles to being considered for transplant.

A study of three safety-net hospitals showed that, among patients whose measures of liver health would typically result in a referral for transplant evaluation, only about one-fourth received the referral. The finding was published June 8 in JAMA Network Open.

A safety-net hospital has a mission or a legal obligation to provide healthcare to individuals regardless of their ability to pay for it.  In the study, each of the three hospitals — LA County and Zuckerberg San Francisco General, both in California, and Harborview Medical Center in Seattle — is affiliated with another medical center that has an active, well-regarded transplant program. 

picture of Dr. Nicole Kim of UW Medicine
A patient’s apparent lack of social support and perceived inability to pay for a lifetime of anti-organ rejection meds could influence a doctor’s decision about referral, said Dr. Nicole Kim, a co-author on the study.

“Patients who receive care at these safety-net hospitals generally do not go to the other hospital unless they have a specific referral,” said Dr. Nicole Kim, a co-author on the paper and a liver transplant fellow at the University of Washington School of Medicine. “Patients who present at safety-net hospitals are often more likely to identify as indigent and underserved, uninsured, lower-income, racial-ethnic minority and-or homeless.”

Although someone’s socioeconomic status might not directly affect their MELD (Model for End Stage Liver Disease) score predicting survival in people with liver disease, a patient’s apparent lack of social support and their perceived inability to pay for a lifetime of anti-organ rejection meds could influence a doctor’s decision about referral, Kim said.

“It’s knowing that for a transplant to be successful, which is the end goal of everyone, the patient must have a support group of people to provide care as they’re recovering,” Kim said. “They also need to be able to acquire medications for the rest of their lives.”

The retrospective study comprised 521 patients who were seen at the three safety-net hospital liver clinics in 2016-17 and followed until 2019. All patients had received a formal diagnosis of cirrhosis, meaning irreversible scarring of the liver, and all had MELD scores of 15 points or greater, “which is routinely the cutoff at which we’d tell a patient, ‘Your liver is sick enough that you may want to consider transplant,’” Kim said.

Of the 521 patients, 145 (27.8%) were referred to a transplant specialist for evaluation — a percentage Kim characterized as “quite low.” The study did not comparatively review the rate of referrals from non-safety-net hospitals among patients with similar stage of liver disease.

The researchers identified three common factors among the patients who did not receive referrals for transplant evaluation: undocumented citizenship, unstable housing and uninsured status. The study identified these traits as “barriers” to referral.

“I think a lot depends on the provider knowing that the patient doesn’t have insurance and-or likely will have difficulty adhering to the medical requirements that accompany transplant, and as a result might tell someone, ‘Maybe now is not the right time for a referral,’” Kim said, who has cared for patients at Harborview’s Liver Clinic.  

The findings highlight the need, Kim said, for safety-net hospitals to better identify patients’ eligibility for insurance or housing that would make them a more viable candidate for transplant — and then help navigate them to those potential resources.

“There are always going to be patients who are not eligible for insurance, who are not eligible for stable housing, for various reasons. But we're really talking about the folks who may be eligible but don't know,” she said. “These are the folks that should be getting that extra level of support to receive the care they need.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases (P30 DK026743, T32DK007742), part of the National Institutes of Health. 

This news item was written by Brian Donohue - 206-543-7856,

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