Can a New Tool Better Screen Liver Transplant Candidates?

Keck Medicine of USC researchers are testing if a standardized screening process is more equitable for candidates — and more precise for providers.

Prescreening is an important first step in identifying suitable organ transplant candidates, especially those with alcohol-associated liver disease. By asking certain questions up front, health care providers can try to ascertain whether a patient might make a good candidate for a liver transplant. Those who are deemed good candidates move forward in the screening process, eventually undergoing a thorough assessment via physical, psychosocial and other evaluations.

There is no typical, standardized approach to prescreening, says Brian P. Lee, MD, a transplant hepatologist with the USC Liver Transplant and Comprehensive Liver Disease Care Center, part of the USC Transplant Institute at Keck Medicine of USC. Candidates are often screened by phone, with someone from the doctor’s office asking the candidate questions. The questions and the process can differ from patient to patient, with interpretations of answers largely subjective to the person conducting the screening.

“There isn’t an established list of standard questions to ask, so the questions candidates are asked could be completely different,” Lee says. “For instance, if a liver doctor is asking the questions, he or she might mainly ask questions related to the medical condition but not ask psychosocial questions that a social worker might ask —which have in fact been shown to be important when screening people for transplant candidacy.”

The results hurt both patients and providers. “Many patients who could be great candidates for transplant don’t make it to an evaluation,” he says. “Studies have shown that this is particularly so with patients with alcohol-associated liver disease. Even though it’s the most common reason why people die from liver disease, this disease is still so stigmatized.”

“What we need,” he says, “is a non-biased, objective approach to make sure that patients are treated equally and fairly during the screening process.”

Creating a psychosocial checklist

A new study published in the journal Liver Transplantation explains a new tool Lee and his Keck Medicine of USC colleagues devised to equalize the prescreening process for determining which candidates should potentially be transferred to Keck Medicine for transplant treatment. The tool is a standardized questionnaire crafted by experts from a range of medical specialties. It is a remotely administered questionnaire, but the questions were carefully written to address a multitude of factors that have been clinically shown to impact who is likely to be a successful transplant candidate — and who isn’t.

The questionnaire focuses on psychosocial determinants. These include a person’s history of alcohol use, whether they’ve been part of an alcohol treatment program or whether they have any history of driving under the influence. Studies associate each of these factors with alcohol relapse after a liver transplant.

The “psychosocial checklist,” as the researchers dub it, examines other factors as well, including a person’s housing situation and what type of social support they have in place.

“Time and time again, social support is always one of the strongest predictors of success after transplant,” Lee explains. “The reality is that transplant takes a large physical and emotional toll, particularly in the immediate period after a transplant. It’s very intensive with medical appointments, lab testing and taking new medications every day. We know, and experience and studies have shown, that it’s extremely important for a transplant recipient to have very strong and stable social support and housing, particularly in the immediate period after transplant.”

To the researchers’ knowledge, he says, this is the first formal, standardized checklist of its kind created for evaluating patients for transfer to a transplant facility. Importantly, none of the components of the questionnaire are absolute contraindications to transplant evaluation.

Questions for the psychosocial checklist were vetted by numerous medical specialists, including liver physicians, transplant surgeons, social workers and addiction specialists.

“We want to make sure this checklist can be consistently administered and that every potential transfer patient is evaluated in the same way,” Lee says.

Checklist in practice

Lee and his team began implementing the psychosocial checklist at Keck Medicine in August 2023. Once it was in use, they began comparing their liver transplant prescreening results with those from a similar time period the year before. They found that the checklist had decreased the odds of patients being unjustly declined for a transplant transfer based on psychosocial reasons.

“Previously, people were being declined for psychosocial reasons due to the non-standardized way of evaluating them,” Lee says. “Now that we’ve standardized prescreening, we think that some of the patients who would have been considered not to be acceptable transplant candidates are actually being found to be acceptable based on their psychosocial profile.”

Using this tool, the USC Liver Transplant and Comprehensive Liver Disease Care Center has seen a 35% increase in the rate of liver transplant listings stemming from hospital transfers.

“It’s interesting because the natural reaction is to think that we’re screening people out. But the opposite is true,” Lee says. “Before, patients might have seemed not to be potential candidates based on skewed questions or sparse documentation; however, when you actually do a more thorough evaluation using this checklist, we actually found more candidates who were acceptable candidates.”

He points out that the center’s transfer acceptance rate remains the same. “We’re not being flooded with new patients or declining more patients. Rather, the takeaway is that we’re doing a better job of selecting the patients who are more likely to be successful transplant candidates.”

The next research step for Lee and his team will be to assess post-transplant outcomes to confirm whether or not their choices actually led to more successful patient outcomes, including fewer transplant patients experiencing alcohol relapse.

Patients themselves also benefit from more careful screening by ensuring they are being directed to the most appropriate care. “It goes both ways,” Lee says. “We’re screening people in who might have previously been turned away due to limited information or biases. But we’re also ensuring that we’re screening people out who would never have been candidates and who would be better served elsewhere.”

“More accurately identifying the right transplant candidates is really in the patient’s best interest,” he adds.

The need to better serve transplant customers with accurate prescreening is great, Lee says, especially given an increase in liver transplant demand in recent years. Following the COVID-19 pandemic, there has been a surge in potential patients needing liver transplants due to increased alcohol use.

Serving each of these patients in the right way and finding them the best and most suitable option for care is critical. “We need to provide equity and access to transplants,” Lee says.

“The reality is that transfer decisions need to happen very quickly, meaning these patients are very sick and we need to decide quickly whether they can be transferred to a transplant facility. The purpose of this screening test is so that this can be done quickly, efficiently and accurately. We’re trying to lead the way in making sure that patients are treated equally and fairly,” he concludes.

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