Financial burden among liver transplant candidates is associated with financial distress and work impairment: A U.S. multicenter study

Background: The financial impact of chronic liver disease among adults undergoing liver transplant (LT) evaluation remains understudied. We performed a cross-sectional multicenter study to explore high financial burden, defined as medical out-of-pocket expenses ≥10% of income (per prior literature), among adult LT candidates. We aimed to identify associations between high financial burden and (1) work productivity impairment; (2) financial distress (material, behavioral, and psychological consequences of financial burden); (3) financial toxicity (health-related quality of life, HRQOL). Methods: From May 2023 to April 2024, 453 patients from 13 United States transplant centers were included. Patients completed questionnaires assessing financial burden, financial distress, financial toxicity (EuroQol EQ-5D-5L instrument), and work productivity and impairment (Work Productivity and Activity Impairment Questionnaire: Specific Health Problem Version). Results: Among LT candidates, 23.3% reported a high financial burden, and only 27.6% were employed. High financial burden was associated with a higher rate of absenteeism from work (34.1% vs. 16.9%, p =0.018) among employed participants. In adjusted models, high financial burden was significantly associated with inability to pay for basic necessities (aOR 4.76, 95% CI: 2.34–9.67), delayed or foregone medical care (aOR 4.02, 95% CI: 2.30–7.02), and psychological distress (aOR 4.63, 95% CI: 1.95–10.98) but was not associated with HRQOL (EQ-5D β: −0.04, 95% CI: −0.08 to 0.00; EQ-5D-VAS β: −4.53, 95% CI: −10.1 to 1.02). Conclusion: These results highlight the critical importance of implementing routine screening for financial burden in this high-risk population and developing strategies to mitigate associated adverse outcomes.