Sociodemographic Predictors of Patient Migration and Waitlist Outcome for Liver Transplantation in the United States

Background: Faced with ongoing organ shortage and regional differences in organ availability, patients requiring liver transplantation may relocate to improve their chance of transplantation.
Objective: To identify predictors of patient migration for liver transplantation in the United States (US), and to evaluate the effect of migration on waitlist outcome.
Design: This is a retrospective cohort study of adult liver transplant candidates and recipients from 2004 to 2016.
Setting: The Organ Procurement and Transplantation Network database represents all transplant and waitlist events in the US.
Patients: Eligible patients included adults living in a zip code with available median income data. Patients listed or transplanted for multi-organ transplantation other than liver-kidney, as Status 1 priority, or with insurance through the Veterans Affairs system, were excluded.
Measurements: Migration was defined as travel to a transplant center greater than 500 miles from a patient’s zip code and outside their home transplant region. We identified sociodemographic factors associated with migration and assessed the impact of migration on waitlist outcomes.
Results: Of 61,007 eligible recipients, 2,066 (3.4%) migrated for transplantation. Migration was associated with non-black race, non-Medicaid payer, residence in a higher income area, and education beyond high school. Of 104,914 primary waitlist registrations during the same period, 2,930 (2.8%) were listed at a distant center. In multivariable competing risk analysis, with liver transplantation as a competing event, distant listing was associated with reduced 1-year waitlist mortality (subdistribution hazard ratio 0.80, 95% CI 0.71-0.90).
Conclusion: Listing at a distant center, which often involves considerable travel and resources, is associated with reduced waitlist mortality. Geographic disparity in access to liver transplantation disproportionately affects minority patients with lower income and public insurance.