MELD 3.0 policy and evolving socioeconomic disparities in liver transplantation

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.