Klassen AC, Klassen DK, Brookmeyer R, Frank RG, Marconi K.
Factors influencing waiting time and successful receipt of cadaveric liver transplant in the United States. 1990 to 1992.
Med Care 1998;36(3):281-94. (Comment in: Med Care. 1998;36(3):252-3.)

Using data from the United Network for Organ Sharing Organ Procurement and Transplantation Network database waiting and recipient lists, the authors examined the influence of medical and nonmedical factors on the length of time patients waited before transplant and whether they survived the wait.

The authors analyzed 7422 entries to the waiting list from October 1, 1990 to December 31, 1992. Time to transplant was modeled by gender, nationality and ethnicity, age, blood type, medical status, transplant number, United Network for Organ Sharing region of the country, and three other measures of supply and demand of organs using Cox proportional Hazard Models. The risk of dying before being allocated an organ was compared with receiving an organ using multiple logistic regression models.

“In addition to differences in medical status, blood type, geographic region, and organ supply and demand, women, Hispanic-Americans, Asian-Americans, and children were found to wait longer for transplant, whereas foreign nationals and repeat transplant patients waited fewer days. The risk of dying before transplant was greater for critically ill and repeat transplant patients, as well as for women, older patients, Asian-Americans, and African-Americans…”

In the multivariate analyses, the “median waiting time varied significantly by ethnicity and nationality. Foreign nationals waited 61 days for a liver transplant, whereas Asian-Americans and Hispanic Americans waited 138 and 107 days, respectively. Native and African-American patients did not vary significantly by waiting time from white patients.”

“Primary care physicians act as gatekeepers to liver transplantation, inasmuch as they recognize liver failure and refer patients to specialists and transplant centers for evaluation.”

“Potential minority disadvantage in waiting time is suggested by these findings…These patterns show a trend of possible disadvantage among several minority patient groups which is a cause for concern. We know that the burden of chronic liver disease falls more heavily on minorities in this country; for example, African-American patients are 1.5 times more likely to die of liver disease than white patients, in part due to a higher incidence of alcohol -related disease. Although the diseases that caused endstage liver failure may be distributed differently among different ethnic groups, there is no known medical evidence related to adverse outcomes for minority patients waiting for liver transplantation. It has been suggested that differences in blood type distribution among ethnic groups could lead to longer waiting times to lover transplantation for minority patients compared with white patients…The present analysis finds racial differences after controlling for blood type, suggesting that other factors must be examined.”

“The relationship between race and poverty may be related to these results…This hypothesis could account for the differences in death rates.”

“Examining the relationships between race and financial reasons for delays in receiving transplants reveals a connection between ethnicity and liver transplant funding…Reviewing 280 liver transplants performed in 1989, …the Med-Cal program was the primary payer for 15% of transplants for white patients compared with 36% of transplants received by minority patients.
This analysis points to a disturbing association: the results indicate some groups (such as nonwhite patients), whom others found to be disadvantaged with respect to gaining access to the waiting list, may continue to experience disadvantage on the waiting list.”