Differential effects of Acuity Circles policy on waitlist outcomes in hepatocellular carcinoma transplantation by region, insurance status, and ethnicity.

Abstract

e23251 Background: The Acuity Circles (AC) policy replaced Donation Service Areas with distance-based sharing to mitigate geographic inequities in Feb 2020. However, concerns persisted that the logistics of broader sharing might disproportionately disadvantage patients with lower socioeconomic status (SES). We investigated whether the intended geographic equalization inadvertently exacerbated disparities among racial minorities and insurance groups. Methods: Using UNOS/OPTN data, we retrospectively analyzed a total of 24,464 adult hepatocellular (HCC) candidates listed during symmetric 21-month periods before and after AC implementation. Time to deceased donor liver transplantation (DDLT) was assessed using adjusted restricted mean failure time (RMFT). Difference-in-differences models were used to estimate differential policy effects across race/ethnicity and insurance status. Results: The policy successfully smoothed geographic extremes: wait times in New York/eastern VT decreased by 58.1 days (95% CI [-77.1, -39.1]; p < 0.001), while those in the Southeast increased by 71.5 days (95% CI [54.2, 88.9]; p < 0.001). Contrary to SES concerns, the policy acted as an economic equalizer, narrowing the waitlist gap for public insurance holders by 12.3 days (95% CI [-16.1, -8.6]; p < 0.001).However, racial impact was heterogeneous. While Asian candidates saw a reduced disparity of 31.8 days (95% CI [-49.8, -13.9]; p < 0.001), the pre-existing gap for Hispanic patients widened by an additional 18.8 days post-policy (95% CI [11.9, 25.8]; p < 0.001). Notably, Texas/Oklahoma also experienced a significant waitlist time deterioration of 34.7 days (95% CI [23.2, 46.2]; p < 0.001). Conclusions: AC succeeded in bridging geographic and economic divides, benefiting public insurance and Asian candidates. However, it paradoxically worsened outcomes for Hispanic candidates. This suggests that heterogeneous geographic shifts - specifically waitlist deterioration in regions with high Hispanic density such as Texas/Oklahoma - may have structurally transferred disadvantages to specific racial groups. Future policy recalibrations must address these geo-racial interactions to ensure equitable access.