Predictors and impact of multiple listing for liver transplantation in the United States across the acuity circles eras.

BACKGROUND: Multi-listing increases the odds of transplantation compared to single-center listing. However, not all patients have equivalent access to multi-listing. The recent allocation policy change prioritized distance from the donor hospital in an attempt to decrease geographic disparities. This study assessed access to liver transplant (LT) given multi-listing practices before and after acuity circles policy change. METHODS: United Network for Organ Sharing data were queried for LTs between January 1, 2016 and November, 1 2024. Patients were grouped by listing at one versus multiple centers and by acuity circle era (ACE). Cohort characteristics and comparisons were described using chi-square and Wilcoxon rank tests. Multivariable logistic regressions and propensity score match (PSM) were performed to assess associations between multi-listing and LT. RESULTS: The final cohort consisted of 105,030 patients; 4,084 (3.9%) were multi-listed. Racial/ethnic minority groups, less educated, and publicly insured candidates were less often multi-listed. Multi-listing was positively associated with LT in all analyses (Overall: OR=1.180, p<0.001; PSM: OR=1.164, p=0.001; pre-ACE: OR=1.127, p=0.015; post-ACE: OR=1.218, p<0.001). Education, race/ethnicity, and insurance type were also associated with LT across all analyses. Multi-listed patients were more often transplanted at their primary center with a significant increase in primary center LT post-ACE (53.4% vs. 63.4%, p<0.001). DISCUSSION: Multi-listing and LT had a positive correlation. There was a negative association between minority groups and multi-listing as well as LT. Although acuity circles decreased geographic disparities, they did not change ML accessibility across candidates.