Katie Ross-Driscoll, PhD, MPH: Disparities in Liver Transplant Referral, Evaluation

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Ross-Driscoll explains how disparities in the liver transplant process begin prior to waitlisting and how findings from her research on referral and evaluation may inform interventions.

Although previous studies have highlighted disparities in liver transplant waitlisting, new research is calling attention to disparities in the referral and evaluation processes preceding waitlisting in patients diagnosed with hepatocellular carcinoma (HCC).

The study leveraged population-based cancer registry data from 2 liver transplant centers in Georgia and found patients who were older and had non-private insurance types were less likely to receive a referral to a transplant center. Of those who were referred to a transplant center, Black patients and those who lived in higher poverty neighborhoods were less likely to initiate a transplant evaluation.

“There's a lot that a patient has to do before they're even considered for a transplant,” Katie Ross-Driscoll, PhD, MPH, assistant professor of surgery at Indiana University School of Medicine and research scientist at the Regenstrief Institute, explained to HCPLive. Specifically, she described how patients must obtain a referral from their diagnosing provider to a specialized transplant center, undergo a series of evaluation appointments, and finally proceed to a listing committee where providers discuss findings from the evaluation appointments.

Ross-Driscoll’s research is one of the first studies to look beyond disparities in the waitlisting process and evaluate earlier steps where patients may not be following through with referral and evaluation, something she described as being important for designing interventions. “If we know that patients aren't being listed, but we don't know anything about where in the process they dropped out, we can't really design interventions in order to help people complete the process and gets transplanted. That's why we thought it was important to look at referral and evaluation as opposed to listing.”

Her study looked at data for incident, adult patients with HCC in Georgia diagnosed between January 1, 2010 and December 31, 2019, and followed them for transplant, death, or loss to follow-up through December 31, 2020. Primary outcomes were the completion of each step of the transplant process prior to waitlisting: referral, evaluation initiation, and evaluation completion.

Among the 1379 patients included in the study, 75% were male, 64% were White, and 46% had Medicare. In total, 26% of patients were referred to liver transplant, with private insurance and younger age associated with increased likelihood of referral. Further analysis revealed patients living in census tracts with ≥20% of residents in poverty were less likely to initiate evaluation among those referred (cause-specific hazard ratio [csHR], 0.62; 95% Confidence interval [CI], 0.42–0.94), and Medicaid patients were less likely to complete the evaluation once initiated (csHR, 0.53; 95% CI, 0.32–0.89).

“One of the main things that I think will be important that we have learned from our findings is that referral is really underutilized, and we think that referral providers might have some different ideas about what makes a transplant candidate eligible as opposed to what the transplant center thinks,” Ross-Driscoll said, adding “We think it'll be important to take a look at barriers for patients who are either not initiating the evaluation or who have initiated it and are have having trouble completing it to understand how we can streamline the process for patients.”


Ross-Driscoll K, Ayuk-Arrey AT, Lynch R, et al. Disparities in Access to Liver Transplant Referral and Evaluation among Patients with Hepatocellular Carcinoma in Georgia. Cancer Research Communications; 4 (4): 1111–1119.