Medicaid Coverage Linked to Lower Liver Transplant Listing Odds in HCC

Key Takeaways

• Among adults with hepatocellular carcinoma referred to six California transplant centers, Medicaid coverage was associated with lower odds of listing and more advanced stage at referral.
• Dual hepatitis C virus and alcohol-associated liver disease was associated with a significantly longer diagnosis-to-referral interval.
• Higher liver-disease severity score, hypertension, chronic dialysis, hepatic encephalopathy, and portal vein thrombosis were associated with mortality.

For adults with hepatocellular carcinoma (HCC), the path to liver transplantation (LT) passes through referral, evaluation, listing, and receipt of an organ. In a study published in Hepatology Communications, investigators retrospectively analyzed 1,573 adults with HCC formally referred to six California Liver Network centers during 2018–2020. The cohort excluded people with HCC who were never referred. Referral meant receipt of a formal evaluation request; evaluation meant an initial transplant-hepatology visit. HCC was identified by Liver Imaging Reporting and Data System (LI-RADS) criteria and/or biopsy, and United Network for Organ Sharing (UNOS) stage was assigned using the most recent imaging at referral. Adjusted logistic models assessed listing, transplantation, and overall mortality; ordinal logistic regression assessed stage; and linear regression assessed days from diagnosis to referral.

The median interval from diagnosis to referral was 124 days. Of the referred adults with HCC, 56.7% were listed, 32.4% received a transplant, and 26.7% died during follow-up. Initial evaluation was nearly universal. Medical or surgical illness, including advanced HCC, and substance-use or psychosocial contraindications were among the principal reasons for declining listing.

Compared with private insurance, Medicaid coverage was associated with lower adjusted odds of listing (OR, 0.55). It was separately associated with more advanced HCC stage at referral. Marriage or domestic partnership and evaluation site were also associated with listing. Male sex, higher alpha-fetoprotein, non-English primary language, and prior HCC treatment type were associated with more advanced stage.

More advanced stage was associated with lower adjusted odds of receiving a transplant; evaluation site was independently associated with transplant receipt. Dual hepatitis C virus (HCV) and alcohol-associated liver disease, as well as prior treatment type, were associated with longer diagnosis-to-referral intervals. Higher Model for End-Stage Liver Disease (MELD) score, hypertension, chronic dialysis, hepatic encephalopathy, and portal vein thrombosis were associated with overall mortality.

The cohort began at formal referral, so these associations cannot characterize people with HCC who were never referred or establish barriers before referral. Retrospective chart abstraction, incomplete documentation of social factors, and unavailable area-level deprivation data also limit interpretation. These U.S. centers operated in California’s competitive organ-allocation setting, and limited Black representation may constrain applicability to other transplant populations. The adjusted associations do not establish causation. No formal mediation analysis was performed to determine the mechanisms underlying these associations.

Among referred adults with HCC, clinical severity, social characteristics, and evaluation site were associated with different steps between diagnosis and transplantation. Listing, organ receipt, stage at referral, and mortality had distinct associated factors.

Clinician Questions

How were T1 and T2 HCC stages defined at liver transplant referral?

For referred adults with HCC, T1 meant one lesion smaller than 2 cm and T2 meant disease within Milan criteria; investigators used the most recent imaging at referral to assign UNOS stage.

How was Medicaid insurance classified for patients with dual coverage during HCC transplant evaluation?

For adults referred to California Liver Network centers, insurance category followed the primary insurer recorded at evaluation. With both Medicare and Medicaid coverage, the designated primary insurer determined the category.

How were incompletely documented social factors handled in adjusted analyses of HCC transplant outcomes?

In this referred cohort, investigators excluded substantially missing variables from primary adjusted models where appropriate, analyzed available patients separately for those variables, and did not impute missing values. This does not show that missing information was unrelated to outcomes.

Recommended Reading

• For more on cirrhosis-related patient outcomes: Malnutrition, Health Literacy Linked to HRQoL in Cirrhosis

This content is intended for healthcare professionals for educational purposes. The article and its image were developed with AI assistance and reviewed by members of the ReachMD team prior to publication. Please refer to the original source linked for the complete and most up-to-date information.

This content is intended for healthcare professionals for educational purposes. The article and its image were developed with AI assistance and reviewed by members of the ReachMD team prior to publication. Please refer to the original source linked for the complete and most up-to-date information.