Evaluation for Liver Transplantation: Adherence to
AASLD Referral Guidelines in a Large Veterans
Venodhar R. Julapalli,1,2Jennifer R. Kramer,1,3and Hashem B. El-Serag1,2,3
Access of patients to liver transplantation involves three
levels: referral for evaluation for transplantation, place-
ment on a waiting list for transplantation, and receipt of a
liver transplant. No study has formally evaluated access to
liver transplantation at the referral level. Therefore, we
sought to estimate the magnitude and determinants of
consideration of liver transplantation in patients at a sin-
gle, large Veterans Affairs medical center. Patients with
liver disease were identified between October 2002 and
September 2003, and their entire medical records were
examined for encounters involving potential indications
for liver transplantation according to American Associa-
tion for the Study of Liver Diseases (AASLD) guidelines,
mention of liver transplantation, and potential contrain-
(20%) of 300 encounters, constituting 41 (21%) of 199
patients satisfying AASLD guidelines for referral. The sig-
liver transplantation were older age (adjusted odds ratio
[OR]: 0.31; 95% confidence interval [CI]: 0.13-0.77, P ?
0.01), alcoholic liver disease (adjusted OR: 0.10; 95% CI:
0.02-0.57, P ? 0.01), and black race (OR: 0.15; 95% CI:
0.02-0.96, P ? 0.045). Most patients had potential con-
traindications that were inferred (but not documented) as
reasons for not being evaluated for transplantation; how-
ever, a small but significant proportion (7%) had no
recorded evidence of contraindications. In conclusion, we
found a low rate of mention of liver transplantation in
patients who satisfied AASLD guidelines for referral, par-
ticularly among patients with alcoholic liver disease and
blacks. Deficiencies at the referral level may lead to dis-
parities at further levels of access to liver transplantation.
(Liver Transpl 2005;11:1370-1378.)
tance as effective treatment for patients with variable
causes of irreversible acute and chronic liver disease.1
1980s have led to sharp increases in patient survival
after orthotopic liver transplantation.1Access to liver
transplantation in the United States involves three lev-
tation, placement of referred patients on a waiting list
for liver transplantation, and allocation of donated liv-
terized access to liver transplantation at the last two
levels.2-7However, to our knowledge no study has for-
mally evaluated access to liver transplantation in the
United States at the referral level. Although many
patients who are referred for possible liver transplanta-
tion may not undergo the procedure due to various
important for health care providers to identify patients
who might benefit from this potentially life-saving pro-
cedure and appropriately refer them for evaluation.
Therefore, we sought to estimate the magnitude and
determinants of consideration of liver transplantation
in patients with liver disease in a single, large Veterans
Affairs (VA) medical center. We defined appropriate
consideration of patients for evaluation for liver trans-
plantation according to the guidelines published by the
American Association for the Study of Liver Diseases
iver transplantation has evolved from its origin as
an experimental procedure in 1963 to its accep-
Materials and Methods
Study Sample and Data Collection
We used the electronic medical records of the Michael E.
DeBakey VA Medical Center to conduct this retrospective
College of Medicine approved the study. This VA center is
one of the largest in the United States; however, it does not
patients seen in outpatient or inpatient departments during
Abbreviations: AASLD, American Association for the Study of
Liver Diseases; VA, Veterans Affairs; ICD-9, International Classifi-
cation of Diseases-Ninth Revision; HCV, hepatitis C virus; HBV,
hepatitis B virus; MELD, Model for End-Stage Liver Disease; HIV,
human immunodeficiency virus; AIDS, acquired immune deficiency
From the1Houston Center for Quality of Care and Utilization
Studies, Houston Veterans Affairs Medical Center; and the2Sections of
Gastroenterology and3Health Services Research, Department of Medi-
cine, Baylor College of Medicine, Houston, TX.
Received January 11, 2005; accepted February 26, 2005.
H.B.E.-S. is a VA HSR&D awardee (RCD00-013-2).
Address reprint requests to Hashem B. El-Serag, MD, MPH, 2002
Holcombe Blvd (152), Houston, TX 77030. Telephone: 713 794 8614;
FAX: 713-748-7359; E-mail: firstname.lastname@example.org
Copyright © 2005 by the American Association for the Study of
Published online in Wiley InterScience (www.interscience.wiley.com).
Liver Transplantation, Vol 11, No 11 (November), 2005: pp 1370-1378
liver disease identified by diagnostic codes from the Interna-
tional Classification of Diseases-Ninth Revision (ICD-9).
These codes included the following diagnoses: acute liver
failure (ICD-9 570), acute alcoholic hepatitis (571.1), alco-
holic cirrhosis (571.2), unspecified alcoholic liver damage
(571.3), nonalcoholic cirrhosis (571.5), esophageal varices
syndrome (572.4), ascites (789.5), and hepatocellular carci-
noma (155.0). We included all patients who had one or more
of the following indications for referral, based on AASLD
guidelines8: variceal bleeding, ascites, spontaneous bacterial
peritonitis, porto-systemic encephalopathy, hepatocellular
carcinoma, hepatorenal syndrome, fulminant hepatic failure,
We then abstracted information from the detailed elec-
unique indications for referral were identified. We used stan-
dardized comprehensive data collection forms designed for
the purpose of this study. A given patient could therefore be
identified as having several encounters for separate indica-
tions, but only one encounter for indications occurring con-
temporaneously. We used the earliest date at which the indi-
cation for referral was documented as the date of the
encounter. For each encounter we recorded the following
demographic features: age, sex, race, and presence of insur-
ance other than VA insurance. We also recorded the etiology
of underlying liver disease: hepatitis C virus (HCV), hepatitis
B virus (HBV), alcoholic liver disease, nonalcoholic steato-
primary sclerosing cholangitis, hemochromatosis, autoim-
mune hepatitis, an “other” etiology, or “idiopathic” cirrhosis.
HBV infection was identified as the presence of HBV surface
antigen. “Other” categories included medication-induced
hepatitis, congestive hepatopathy, and cirrhosis suggested by
computed tomography imaging. Patients could have had
more than one etiology. “Idiopathic” cirrhosis denoted the
absence of any of the above etiologies. From available clinical
and laboratory information we recorded the severity of liver
disease as defined by the Child-Turcotte-Pugh score at the
time of each encounter. We also calculated the Model for
End-Stage Liver Disease (MELD) score11for each encounter.
We then identified and recorded potential contraindica-
use, active recreational drug use, coronary artery disease, con-
gestive heart failure, chronic obstructive or restrictive lung
disease, morbid obesity, uncontrolled systemic infection,
human immunodeficiency virus (HIV) infection or acquired
immune deficiency syndrome (AIDS), extrahepatic malig-
nancy within 5 years of the encounter, disseminated hepato-
cellular carcinoma, an uncontrolled psychiatric or neurologi-
cal disorder, or thrombosis of the mesenteric and portal
venous system. Active alcohol or drug use was defined as the
use of any amount of alcohol or drugs, respectively, within 6
months of the encounter. Disseminated hepatocellular carci-
noma referred to one mass greater than 5 cm in diameter, the
largest of three masses greater than 3 cm, extrahepatic spread,
or macrovascular invasion.
Finally, we attempted to determine adherence to guide-
for the following outcomes: (1) any mention of liver trans-
plantation in the medical record within 1 year of an encoun-
ter, (2) documented intention of referral for possible liver
transplantation, and (3) documented consultation initiated
by a referral. For encounters that did not result in either
mention of or referral for possible transplantation, we ascer-
tained reasons for the lack of mention/referral. These reasons
could be either documented (written in the record as reasons
for not referring), or inferred (recorded in any other context
but as reasons for unsuitability of liver transplantation).
We defined the primary outcome of interest as mention of
liver transplantation in the medical record. We compared the
distribution of the following variables between patient
encounters with mention of liver transplantation and those
without mention: demographic characteristics, etiologies of
underlying liver disease, potential indications for liver trans-
plantation, severity of liver disease, and potential contraindi-
cations to liver transplantation. When comparing individual
patients, we used t tests and chi-square tests to compare con-
ing encounters, we used a nonlinear mixed modeling tech-
nique for univariable and multivariable analyses to account
for the potential clustering of multiple encounters within
value of 0.25 or less in univariable analyses were included in
95% confidence intervals with respect to mention of liver
transplantation. We constructed a final, most parsimonious
model by removing variables with the highest Wald P values
one at a time and running a new model; we repeated this
than 0.05. We performed all analyses with SAS (Cary, NC)
Characteristics of the Patients
We identified a total of 352 inpatient or outpatient
encounters involving 251 patients with ICD-9 codes
for liver disease between October 1, 2002, and Sep-
tember 30, 2003 (Fig. 1). We excluded 52 patients
because we could not confirm liver disease (n ? 6) or
potential indications for liver transplantation referral
(n ? 46). There were 300 encounters involving 199
patients for which guidelines for referral for possible
liver transplantation were satisfied. As expected at
Evaluation for Liver Transplantation
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