Changes in the liver transplant evaluation process during the early COVID-19 era and the role of telehealth

Table 1 Overall cohort demographics and outcomes of patients evaluated before and after coronavirus disease 2019, n (%)

	Pre-COVID era, n = 178	COVID era, n = 199	P value
Median age, years (p 25-p 75)	62 (55-67)	58 (47-65)	0.002
Sex (male)	112 (64.0)	129 (64.8)	0.85
Preferred language other than English	45 (25.3)	40 (20.1)	0.28
Race/ethnicity			0.89
White	90 (50.6)	93 (46.7)
Asian	13 (7.3)	17 (8.5)
Hispanic	66 (37.1)	79 (39.7)
Black	2 (1.1)	4 (2.0)
Other	7 (3.9)	6 (3.0)
Insurance			0.78
Private	63 (35.4)	75 (37.7)
Medicare	66 (37.1)	67 (33.7)
Medi-cal	49 (27.5)	57 (28.6)
Etiology of liver disease
Hepatitis C only	21 (11.8)	18 (9.0)
Hepatitis C + alcohol induced liver disease	15 (8.4)	11 (5.5)
Alcohol induced liver disease only	73 (41)	92 (46.2)
Hepatitis B	9 (5.1)	5 (2.5)
Primary sclerosing cholangitis	4 (2.2)	4 (2.0)
Primary biliary cholangitis	4 (2.2)	6 (3.0)
Autoimmune hepatitis	1 (0.6)	5 (2.5)
Non-alcoholic steatohepatitis	36 (20.2)	32 (16.1)
Alpha 1 anti-trypsin	1 (0.6)	1 (0.5)
Wilson’s disease	0 (0.0)	1 (0.5)
Hemochromatosis	14 (7.9)	24 (12.1)
Median MELD-Na at evaluation (p 25-p 75)
All patients	17 (9-23)	21 (13-29)	< 0.001
Outpatient only	13 (8-19)	16 (10-20)	0.02
Median distance to Stanford Hospital (p 25-p 75) miles	58.0 (17.1-114.3)	58.6 (15.8-131.8)	0.91
Alcohol etiology	88 (49.4)	103 (51.8)	0.73
HCC diagnosis	60 (33.7)	42 (21.1)	0.008
Hepatology liver transplant evaluation			< 0.001
Office visit	128 (71.9)	62 (31.2)
Telehealth	0 (0.0)	58 (29.1)
Inpatient	50 (28.1)	79 (39.7)
Median days from evaluation to initial committee review (p 25-p 75)
All patients	26 (11-60)	13 (6-48)	0.004
Outpatient only	38 (15-69)	32 (11-69)	0.48
COVID era median days from evaluation to initial committee review (p 25-p 75)
Office visit	N/A	29 (11-63)	0.5
Telehealth	N/A	37.5 (11.3-74.8)
Median days from evaluation to listing (p 25- p 75)
All patients	35 (18-81)	19 (7-69)	0.02
Outpatient only	41 (19-104)	45 (11-102)	0.54
COVID era median days from evaluation to listing (p 25-p 75)
Office visit	N/A	46 (11-102)	0.9
Telehealth	N/A	42 (12-92.5)
Listed	100 (56.2)	115 (57.8)	0.83
COVID era listed
Office visit	N/A	41 (66.1)
Telehealth	N/A	28 (48.3)	0.07
Pre transplant mortality
All patients	N/A	51 (25.6)	N/A
Outpatient only		25 (20.8)
COVID era pre transplant mortality			0.25
Office visit	N/A	16 (25.8)
Telehealth	N/A	9 (15.5)
Transplanted	N/A	59 (29.6)	N/A
COVID era transplanted
Office visit	N/A	13 (21.0)	0.8
Telehealth	N/A	14 (24.1)

COVID: Coronavirus disease; MELD-Na: Model for end-stage liver disease with sodium; HCC: Hepatocellular carcinoma; N/A: Not applicable.

Table 2 Predictors of telehealth use among outpatients during the coronavirus disease 2019 era

	Univariable OR (95%CI)	P value	Multivariable OR (95%CI)	P value
Age (per year increase)	1.01 (0.98-1.05)	0.46	1.01 (0.96-1.05)	0.78
Sex, male	0.58 (0.27-1.24)	0.16	0.64 (0.26-1.59)	0.34
Preferred language, non-English	0.91 (0.39-2.11)	0.82	0.97 (0.31-3.02)	0.97
Race/ethnicity (ref: White)
Hispanic	0.67 (0.30-1.49)	0.33	0.64 (0.23-1.78)	0.39
Asian	1.40 (0.44-4.45)	0.57	2.01 (0.47-8.56)	0.34
Other	0.47 (0.08-2.75)	0.4	0.34 (0.03-3.94)	0.39
Insurance (ref: Private)
Medicare	1.92 (0.83-4.46)	0.13	1.85 (0.61-5.62)	0.28
Medi-cal	1.86 (0.72-4.80)	0.2	1.73 (0.55-5.40)	0.35
MELD-Na at evaluation (per unit increase)	0.97 (0.91-1.03)	0.3	0.96 (0.89-1.04)	0.29
Distance to Stanford Hospital (per 50 miles)	0.93 (0.76-1.14)	0.48	0.94 (0.74-1.20)	0.62
Alcohol etiology	1.38 (0.67-2.85)	0.38	1.96 (0.78-4.90)	0.15
HCC diagnosis	1.11 (0.52-2.36)	0.8	0.67 (0.23-1.98)	0.47

MELD-Na: Model for end-stage liver disease with sodium; HCC: Hepatocellular carcinoma.

Table 3 Univariable and multivariable linear regression evaluating predictors of time to committee review during coronavirus disease 2019 era

	Univariable beta	P value	Multivariable beta	P value
Age	0.41	0.12
Sex, male	-14.6	0.03	-15.38	0.02
Preferred language, non-English	10.99	0.18
Race/ethnicity (ref: White)
Hispanic	-0.56	0.06	1.18	0.86
Asian	23.22	0.5	14.6	0.2
Other	-10.48	0.94	-8.92	0.53
Insurance (ref: Private)
Medicare	-21.91	0.005	-17.11	0.02
Medi-cal	-9.46	0.25	-4.84	0.55
Hepatology visit type (ref: Office visit)
Telehealth	5.4	0.5	1.48	0.85
Inpatient	-31.9	< 0.001	-36.7	< 0.001
MELD-Na at evaluation	-1.12	< 0.001	0.34	0.43
Distance to Stanford Hospital	-0.008	0.84
Alcohol etiology	8.05	0.22
HCC diagnosis	1.9	0.81

MELD-Na: Model for end-stage liver disease with sodium; HCC: Hepatocellular carcinoma.

Table 4 Univariable and multivariable linear regression evaluating predictors of time to listing during coronavirus disease 2019 era among those ultimately listed

	Univariable beta	P value	Multivariable beta	P value
Age	0.2	0.72
Sex, male	-17.5	0.22
Preferred language, non-English	14.64	0.39
Race/ethnicity (ref: White)
Hispanic	-2.18	0.88
Asian	15.02	0.53
Other	-7.73	0.78
Insurance (ref: Private)
Medicare	35.96	0.02	17.46	0.02
Medi-cal	31.2	0.08	11.52	0.13
Hepatology visit type (ref: Office visit)
Telehealth	-15.1	0.37	2.1	0.79
Inpatient	-51.39	< 0.001	-33.78	< 0.001
MELD-Na at evaluation	-0.85	0.18
Distance to Stanford Hospital	-0.02	0.79
Alcohol etiology	32.48	0.02	13.54	0.03
HCC diagnosis	-24.26	0.13

MELD-Na: Model for end-stage liver disease with sodium; HCC: Hepatocellular carcinoma.

Table 5 Predictors of pre-transplant (pre- or waitlist) mortality, outpatients only, coronavirus disease 2019 era

	COVID era	P value
Hepatology liver transplant evaluation - telehealth	0.50 (0.19-1.33)	0.17
Race/ethnicity (ref: White)
Hispanic	2.81 (1.01-7.79)	0.05
Asian	0.52 (0.09-2.90)	0.45
Other	Inf
Insurance (ref: Private)
Medicare	1.20 (0.41-3.54)	0.74
Medi-cal	0.43 (0.11-1.63)	0.22
Distance to Stanford Hospital (per 50 miles)	0.73 (0.49-1.08)	0.12
MELD-Na at evaluation (per unit increase)	1.00 (0.93-1.08)	0.91

COVID: Coronavirus disease; MELD-Na: Model for end-stage liver disease with sodium.