Acuity circles policy and persistent socioeconomic disparities in liver transplantation

Background: The Acuity Circles policy, implemented by UNOS on April 2, 2020, aimed to improve geographic equity in liver transplantation by prioritizing local candidates with high medical acuity. However, concerns remain about whether this policy adequately addresses persistent socioeconomic disparities in transplant access. We evaluated the impact of Acuity Circles on disparities in deceased donor liver transplant (DDLT) rates across socioeconomic factors including race/ethnicity, insurance status, education, employment, citizenship, and geographic region. Methods: Using UNOS data from adult HCC patients listed for liver transplant, we analyzed 13,589 patients in the 21-month periods before (n=7,380) and after (n=6,209) Acuity Circles implementation. We employed competing risks analysis with Aalen-Johansen cumulative incidence functions to estimate DDLT rates, accounting for death/deterioration as competing events. Socioeconomic disparities were assessed using Gray's test for equality of cumulative incidence functions. Time origin was listing date with era-specific censoring. Results: Overall DDLT rates were comparable between the pre- and post-policy eras: 49.5% at 12 months pre-policy vs. 48.1% post-policy (Gray's test p=0.93). Regarding race/ethnicity, pre-policy, Asian patients had DDLT rates of 44.0% vs. 50.0% for White patients (reference) and 54.9% for Black patients. Post-policy, Asian rates remained lower at 44.9% vs. 49.0% for White patients, with Black patients at 52.7% (Gray's test: pre p<0.001, post p<0.001). By insurance status, private insurance patients maintained higher DDLT access compared to public insurance patients in both eras (Gray's test: pre p=0.002, post p=0.012). For education, patients with less than college education had slightly different DDLT rates compared to college graduates in both periods (49.4% vs. 48.0% pre-policy, 47.3% vs. 47.5% post-policy; Gray's test p<0.001 both eras). Additionally, US citizens had higher access than non-US citizens (p=0.001 pre, p=0.009 post), employed patients had better access than unemployed (p<0.001 both eras), and significant regional variation remained (p<0.001 both eras). Gender differences were not significant. Conclusions: The Acuity Circles policy did not significantly alter overall DDLT rates or reduce existing socioeconomic disparities in liver transplantation. Despite its goal of improving geographic equity, race/ethnicity, insurance, employment, citizenship, and regional disparities persisted at similar magnitudes before and after implementation. These findings highlight the need for complementary policy interventions that directly address socioeconomic determinants of transplant access beyond geographic redistribution of organs.