PO.PS01.05 · 人群科学
MELD 3.0政策与肝移植中不断演变的社会经济差异
MELD 3.0 policy and evolving socioeconomic disparities in liver transplantation
作者与单位 Authors & Affiliations
摘要 Abstract
中文摘要
背景：MELD 3.0政策由UNOS于2023年7月13日实施，更新了肝脏分配评分系统以更好地反映90天死亡风险。尽管其意图是改善移植公平性，但对其在社会经济差异方面的影响仍存在疑问。我们考察了MELD 3.0如何影响各社会经济群体的DDLT（尸体供肝肝移植）可及性，以及它是缩小还是扩大了现有差异。
方法：我们使用UNOS数据分析了MELD 3.0实施前（n=6,154）和实施后（n=6,325）各21个月期间的12,479名成人HCC患者。采用Aalen-Johansen估计量的竞争风险分析评估DDLT率，同时考虑死亡/病情恶化。Gray检验评估按种族/族裔、保险、教育、就业、公民身份、性别和地区划分的DDLT可及性社会经济差异。各时期的删失以列入等待名单日期作为时间起点。
结果：MELD 3.0的实施在12个月时显著改善了DDLT率：政策前53.3% vs. 政策后62.2%（+8.9个百分点，p<0.001）。社会经济差异呈现出混合模式。种族/族裔差异持续存在并略有扩大：亚裔患者从49.0%改善至54.7%，而白人患者从55.1%上升至64.3%。黑人患者从55.1%上升至59.5%，西班牙裔患者从46.1%上升至64.8%，差异仍具有显著性（政策前p<0.001，政策后p<0.001）。
教育差异保持极小：低于大学学历者与大学毕业者在政策前（53.0% vs. 53.2%）和政策后（62.5% vs. 62.1%）的比率相似，其显著性反映的是样本量而非有意义的差异（两个时期均p<0.001）。
保险差异呈现混合结果：私人保险相对公共保险维持优势，尽管显著性减弱（政策前p=0.015，政策后p=0.043）。
公民身份差异在绝对差异上略有缩小（美国 vs. 非美国：政策前53.4% vs. 51.0%；政策后62.3% vs. 60.7%），而统计显著性增强（政策前p=0.047，政策后p=0.010）。
就业和地区差异持续存在：政策后，在业患者的可及性略高，且地区间差异仍然显著（两个时期均p<0.001）。性别差异仍不显著。
结论：MELD 3.0改善了HCC患者的整体DDLT可及性，但对社会经济差异的影响各异。教育差异保持极小，而种族/族裔、保险、就业、公民身份和地区差异持续存在。尽管MELD 3.0提升了移植可及性，但持续存在的差异凸显了在分配评分优化之外，还需针对社会经济决定因素采取额外干预措施。
查看英文原文 English abstract
Background: The MELD 3.0 policy, implemented by UNOS on July 13, 2023, updated the liver allocation scoring system to better reflect 90-day mortality risk. While intended to improve transplant equity, questions remain about its impact on socioeconomic disparities. We examined how MELD 3.0 affected DDLT access across socioeconomic groups and whether it narrowed or widened existing disparities.
Methods: We analyzed 12,479 adult HCC patients in the 21-month periods before (n=6,154) and after (n=6,325) MELD 3.0 implementation using UNOS data. Competing risks analysis with Aalen-Johansen estimators assessed DDLT rates accounting for death/deterioration. Gray's test evaluated socioeconomic disparities in DDLT access by race/ethnicity, insurance, education, employment, citizenship, gender, and region. Era-specific censoring used listing date as time origin.
Results: MELD 3.0 implementation significantly improved DDLT rates at 12 months: 53.3% pre-policy vs. 62.2% post-policy (+8.9 percentage points, p<0.001). Socioeconomic disparities showed mixed patterns. Race/ethnicity disparities persisted and slightly widened: Asian patients improved from 49.0% to 54.7%, while White patients increased from 55.1% to 64.3%. Black patients rose from 55.1% to 59.5%, and Hispanic patients from 46.1% to 64.8%, with differences remaining significant (pre p<0.001, post p<0.001).
Education disparities remained minimal: less than college vs. college graduates had similar rates pre-policy (53.0% vs. 53.2%) and post-policy (62.5% vs. 62.1%), with significance reflecting sample size rather than meaningful differences (p<0.001 both eras).
Insurance disparities showed mixed results: private insurance maintained advantage over public insurance, though significance weakened (p=0.015 pre, p=0.043 post).
Citizenship disparities showed a slight reduction in absolute difference (US vs. non-US: 53.4% vs. 51.0% pre; 62.3% vs. 60.7% post), while statistical significance strengthened (p=0.047 pre, p=0.010 post).
Employment and regional disparities persisted: post-policy, employed patients had slightly higher access, and substantial regional variation continued (p<0.001 both eras). Gender differences remained non-significant.
Conclusions: MELD 3.0 improved overall DDLT access for HCC patients but had varied effects on socioeconomic disparities. Education disparities remained minimal, while race/ethnicity, insurance, employment, citizenship, and regional differences continued. Although MELD 3.0 enhanced transplant access, persistent disparities highlight the need for additional interventions targeting socioeconomic determinants beyond allocation score refinements.
利益披露 Disclosure
T. Eom, None..
J. Song, None..
H. Ku, None..
S. Park, None..
M. Kim, None..
S. Kim, None..
S. Lee, None..
H. Kim, None..
S. Ku, None..
H. Kim, None..
A. Choi, None..
C. Jo, None.