Pediatric liver transplant patients from economically deprived neighborhoods were more likely to experience graft failure than those from wealthier areas — but not when they were treated at centers with below-average overall failure rates, a researcher reported.
Among 66 centers performing liver transplants in 2,804 children during 2008-2013, the average graft failure rate was 22.3%, said Sharad Wadhwani, MD, MPH, of the University of California San Francisco, during an online presentation at the virtual American Association for the Study of Liver Diseases annual meeting.
When patients’ neighborhoods were evaluated for socioeconomic status on a scale of 0 to 1 — with 1 representing the greatest deprivation — each 0.1-point increment was associated with a 32% increase in risk for graft failure (95% CI 5%-66%) after adjustment for patients’ diagnoses (acute liver failure vs tumor) and performance status.
But neighborhood ratings made no difference in event-free survival at centers with failure rates below 22.3%, Wadhwani said. Event-free graft survival was roughly 85% at those centers irrespective of whether their patient mix was dominated by patients from low- versus high-status neighborhoods.
Similarly, graft survival rates were nearly identical for neighborhood status — though much lower, of course, at about 60% — at centers with failure rates above the 22.3% average.
“Center-specific practices may mitigate the effects of neighborhood deprivation on poor outcome,” Wadhwani said.
Session co-moderator Elliot Tapper, MD, of the University of Michigan in Ann Arbor, wondered whether the results would have differed if Wadhwani and colleagues had treated center performance “as a continuous variable rather than binary.”
Wadhwani responded that his group had indeed looked at that, and found similar results. For presentation, they settled on the binary approach, he said, because “we conceptualized that patients at high-performance and low-performance centers would have a different baseline hazard of graft failure” — presumably because of center-specific characteristics rather than factors associated with their patients.
What might those characteristics be? Wadhwani cited a National Academy of Medicine report on integrating “social needs into medical care,” as he put it.
“Two activities that healthcare systems can take on to better adjust social needs [are] care assistance, such as providing transportation vouchers to help patients get to their clinic appointments, and care adjustment,” he said. “One example of [the latter] would be to use virtual visits for patients with transportation challenges. So one of the things I would be interested in finding out about these high-performing centers is how systematically they adjust care and assist with social needs for children who have those needs.”
For the study, Wadhwani and colleagues drew on data from the Scientific Registry of Transplant Recipients for patients younger than 18 undergoing liver transplant.
Neighborhood deprivation status was evaluated at the ZIP code level, based on Census Bureau data from the American Community Survey.
Last Updated November 17, 2020
Study authors had no relevant financial interests.
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