Barriers hindering referral to liver transplantation: insights from a survey

Background: Improving equity and fairness in the referral process for liver transplantation remains a critical unmet need. Multilevel barriers continue to limit timely and appropriate access to liver transplantation evaluation. This study aimed to identify key obstacles to liver transplantation referral and to explore potential strategies to overcome them. Methods: An online survey was sent to all centers participating in a Hub-and-Spoke liver transplantation referral network in Northern Italy. The survey addressed barriers related to patient, healthcare system, and practice setting-level factors. Healthcare providers (HCPs) were also asked to rate the perceived usefulness of six proposed actions designed to reduce or prevent referral barriers. Results: A total of 58 responses were collected. Nonadherence, lack of a caregiver, and absence of motivation toward liver transplantation (85%, 82%, and 78%, respectively) were perceived as the most impactful patient-related barriers. Lack of real-time technological communication for data sharing and limited social worker availability were identified as major practice setting-related barrier by 77% and 44.5% HCPs. Lack of knowledge about liver transplantation and unclear indications for liver transplantation were perceived significant healthcare-related barriers by 25% and 21% of HCPs, respectively. All six proposed actions to improve the referral process were rated as clinically impactful by at least 60% of HCPs. Conclusion: Multilevel barriers may still hinder the referral of potential liver transplantation candidates. Implementation of structured psychosocial support and real-time data sharing between centers could significantly reduce inequities in referral to liver transplantation.