Access to Evaluation for Liver Transplantation in the Veterans Health Administration

As the largest US provider of cirrhosis care, the Veterans Health Administration (VA) is the ideal setting to assess patient-, clinician-, and site-level barriers to transplant evaluation.

To assess barriers to transplant evaluation referral among Veterans with cirrhosis or hepatocellular carcinoma (HCC).

Logistic regression assessed facility, patient, clinical, and distance factors associated with transplant referral for Veterans with cirrhosis or HCC, over 1 year. VA clinicians were surveyed to understand barriers to transplant evaluation.

Of 81,219 Veterans, 10% had HCC, 44% had compensated, low-MELD-Na (< 15) cirrhosis, 33% had MELD-Na > 15 or decompensated cirrhosis, and 13% had no recorded MELD-Na; 700 were referred for transplant evaluation over 1 year. Younger age, white race, being married, having fewer comorbidities, and having more severe disease or HCC were significantly associated with transplant referral. Distance to VA Transplant Center was associated with transplant referral for patients with HCC, but not for patients with cirrhosis and no HCC. Adding a random effect for facility variability reduced the importance of distance and facility complexity in models predicting referral for transplant evaluation and improved model fit. Among 196 clinician survey respondents, frequently cited transplant referral barriers included confusion about non-VA care, perceived complexity, and knowledge about processes and policies regarding alcohol, live donor transplant, and non-VA care.

Multiple site, clinician, and patient variables were associated with liver transplant referral probability. Identifying addressable barriers such as education for VA clinicians is a first step toward improving transplant referral for at-risk Veterans.