Time to transplant by sociodemographic group following MELD 3.0 implementation in hepatocellular carcinoma.

Abstract

e23208 Background: The MELD 3.0 policy was implemented in July 2023 to improve mortality prediction and address allocation inequities through updated creatinine parameters and sex-based coefficients. Although designed to enhance equity and efficiency, its impact on hepatocellular carcinoma (HCC) candidates - who rely heavily on exception points - remains unclear. We examined whether MELD 3.0 improved time to transplant equitably across sociodemographic groups. Methods: Using UNOS/OPTN data, we retrospectively analyzed 5,896 adult HCC candidates listed during symmetric 21-month periods before (n = 3,435) and after (n = 2,461) MELD 3.0 implementation. Time to transplant was assessed using adjusted restricted mean failure time (RMFT). Difference-in-differences models were used to estimate differential policy effects by sex and race/ethnicity. Results: Overall, MELD 3.0 was associated with shorter wait times for transplantation. Compared with the pre-implementation era, adjusted RMFT decreased by 102.4 days for male candidates and 93.3 days for White candidates ( p < 0.001). However, subgroup effects were heterogeneous. A new sex-based disparity emerged, with female candidates experiencing a 16.6-day longer wait time than male candidates ( p < 0.001), whereas no difference existed pre-implementation. Racial disparities also evolved unevenly. The Black–White gap in wait time widened from 30.7 days pre-MELD 3.0 to 67.9 days post-implementation ( p < 0.001). In contrast, the Asian–White gap narrowed and was no longer statistically significant (37.6 to 16.3 days, p = 0.18). Hispanic candidates experienced partial improvement, though a significant gap persisted (15.9 days, p < 0.001). Conclusions: MELD 3.0 improved overall time-to-transplant efficiency for HCC candidates but was associated with heterogeneous equity effects. Despite system-wide gains, a new disadvantage emerged for women and racial disparities for Black candidates widened, while disparities for Asian candidates were mitigated. These findings highlight the need for continued policy refinement to ensure equitable access to transplantation.