Improved Center-Specific Practices May Ease Effects of Socioeconomic Deprivation for Pediatric Liver Transplant Recipients

ALEXANDRIA, VA – Data from a new study presented this week at The Liver Meeting Digital Experience^® – held by the American Association for the Study of Liver Diseases – found that while neighborhood socioeconomic deprivation is associated with worse adverse long-term outcomes after liver transplant in children, improving center-specific practices can mitigate these effects for young at-risk patients.

Past research shows that neighborhood socioeconomic deprivation─ area characterized by poor housing, social and economic disadvantage─ is associated with negative outcomes like graft failure and even death in children after a liver transplant. This study’s goal was to evaluate whether the effect of socioeconomic deprivation on transplant outcomes varies by center.

“Given that our previous work found that children from socioeconomically deprived neighborhoods had increased risk for graft failure and death, we wanted to better understand the role of the transplant center,” says study author Sharad Wadhwani, MD, MPH, assistant professor, pediatrics, at the University of California San Francisco School of Medicine. “Specifically, we were interested in learning whether certain centers who care for predominately socioeconomically deprived children are able to attain excellent outcomes while also primarily serving these particularly vulnerable children. If there were such centers, then we could learn from them and apply these learnings in other transplant centers with the hopes of realizing more equitable outcomes.”

The researchers analyzed Scientific Registry of Transplant Recipients (SRTR) data from 2008 to 2013 from any patient under 18 who received a liver transplant. They matched patients to a validated socioeconomic deprivation index by their home ZIP code, identifying 2,474 out of 2,804 eligible patients. The primary measurement in the study was the median patient deprivation index of a transplant center, or patient-mix deprivation. Transplant centers were grouped as either high- or low-performing based on whether their 10-year graft survival rates were above or below the overall rate of the study cohort.

Out of 2,474 pediatric liver transplant recipients, the mean deprivation index was 0.38±0.12, which is  similar to that of the entire U.S. population. The overall 10-year graft survival was 78 percent. Each 0.1 unit increase in center deprivation was associated with an increased hazard of graft loss.

The researchers found other center-level characteristics associated with graft loss in children after liver transplant, including the cause of liver disease and average laboratory MELD/PELD (Model for End-Stage Liver Disease and its pediatric equivalent, standard measurements of a patient’s urgent need for transplant) score at transplant. In their multivariable analysis, center deprivation remained significantly associated with graft loss in pediatric patients, even after adjusting for center-level co-variables, such as cause of liver disease . However, when they performed Cox regression – a method for investigating the effect of multiple variables involved in a specific event ─ stratified by center performance status, the effect of center deprivation on adverse outcomes was no longer associated with graft failure.

More research is needed to identify potential practices that could create more equitable outcomes for these patients, the researchers concluded.

“This study uncovers significant center-to-center variability with regards to long-term outcomes for children undergoing liver transplantation. Importantly, we found that there are certain centers caring for children from predominantly high-deprivation neighborhoods who realize excellent post-transplant outcomes,” says Dr. Wadhwani. “These data demand that we learn from these centers to uncover the center-specific practices that might contribute to these equitable outcomes. Furthermore, regulatory agencies such as UNOS should benchmark and report long-term outcomes and socioeconomic inequities in outcomes by center to further incentivize equitable care for these particularly vulnerable children.”

Dr. Wadhwani will present these findings at The Liver Meeting Digital Experience ™  during Parallel: Health Services Research and Public Health on November 16 at 10:30 AM ET. The corresponding abstract “Center-Level Variation in Long-Term Outcomes for Children Undergoing Liver Transplantation: Does a Child’s Home Neighborhood Matter?“ can be found in the journal, HEPATOLOGY.

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