An Analysis of Free‐Text Refusals as an Indicator of Readiness to Accept Organ Offers in Liver Transplantation

Abstract

Racial/ethnic minorities experience higher rates of wait‐list mortality and longer waiting times on the liver transplant wait list. We hypothesized that racial/ethnic minorities may encounter greater logistical barriers to maintaining “readiness” on the wait list, as reflected in offer nonacceptance. We identified all candidates who received an organ offer between 2009 and 2018 and investigated candidates who did not accept an organ offer using a free‐text refusal reason associated with refusal code 801. We isolated patients who did not accept an organ offer due to “candidate‐related logistical reasons” and evaluated their characteristics. We isolated 94,006 “no 801” patients and 677 “with 801 logistical” patients. Common reasons for offer decline among the 677 were 60% “unable to travel/distance,” 22% “cannot be contacted,” 13% “not ready/unspecified,” and 5% “financial/insurance.” Compared to “no 801,” “with 801 logistical” patients were more likely to be Hispanic (19% vs. 15%, P < 0.01). Multivariate logistic modeling showed Hispanic (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17‐1.76, P < 0.01) and multiracial/other ethnicity (OR 1.82, 95% CI 1.08‐3.05, P = 0.02) were associated with “with 801 logistical” status. The “with 801 logistical” patients were listed with higher allocation (inclusive of exception points) Model for End‐Stage Liver Disease scores (16 vs. 15, P < 0.01) and remained longer on the wait list (median 428 days vs. 187 days, P < 0.01). Conclusion: In this analysis of wait‐list candidates, we isolated 677 patients who declined an organ offer with a free‐text reason consistent with a “candidate‐related logistical reason.” Compared with non‐Hispanic Whites, Hispanics were at 1.44 odds of not accepting organ offers due to logistical reasons. These limited findings motivate further research into interventions that would improve candidates’ “readiness” to accept organ offers and may benefit racial/ethnic minorities on the liver‐transplantation wait list.