Systematic inequalities in access to liver transplantations within a universal healthcare system
Darius Barimani, Magnus Holmer, Carl Jorns, Juan Vaz, Hannes HagströmAbstract
Introduction
In universal healthcare systems such as Sweden, access to liver transplantation (LT) is expected to be equitable. However, whether disparities persist despite universal coverage remains unclear. We investigated whether access to LT varies by sociodemographic, clinical, and regional factors.
Methods
In this nationwide cohort study, we included 21 223 adults aged 18–75 years with cirrhosis following a first recorded major adverse liver outcome (MALO) between 2002 and 2021. Individuals were followed until LT, death, emigration, or end of follow-up. Cumulative incidence functions (CIF) estimated probabilities of LT and mortality, accounting for competing risks. Multivariable Cox regression models assessed factors associated with LT.
Results
During 64 248 person-years of follow-up, 1536 individuals (7%) underwent LT and 14 932 (70%) died. The 1- and 5-year cumulative incidences of LT were 4.0% and 7.1%, compared with 37.9% and 63.7% for death. Lower access to LT was independently associated with older age, female sex, lower income and education, and unmarried status. Patients with alcohol-related liver disease (ALD) and metabolic dysfunction–associated steatotic liver disease (MASLD) had markedly reduced access compared with viral hepatitis, whereas autoimmune liver disease showed higher access. Regional variation persisted after adjustment, with higher access in regions served by the Gothenburg transplant center compared with Stockholm, and lower access in several Stockholm-affiliated regions.
Discussion
Substantial socioeconomic and regional inequalities in access to LT persist within a universal healthcare system. These disparities are not fully explained by case-mix, suggesting that structural factors influence access and may have broader relevance.