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Persistent Gender Disparity In Liver Transplantation
*Michael Darden1, *Geoffrey Parker2, *Ed Anderson3, Joseph F Buell4
1Carey School of Business, Johns Hopkins University, Baltimore, MD;2Thayer School of Enginnering, Dartmouth College, Hannover, NH;3Dell School of Medicine, Austin, TX;4Mission Health, University of North Carolina Asheville, Asheville, NC

Objective: Women achieve higher life expectancies following liver transplantation then men, yet conditional on wait list registration they have consistently been transplanted at a rate four to five percent less than men. Recent literature has contribute the majority of this disparity to the physiologic components of the MELD score but this appears to unlikely.
Methods: Retrospective logistic analysis of the United Network of Organ Sharing (UNOS) Standard Transplant Analysis Research (STAR) data from 1994 through 2012 was used to evaluate competing explanations for the observed gender disparity in a final sample consisting of 150,149 patients.
Results: The unadjusted difference in transplantation by gender was 4.8 percentage points (p<0.001). Adjustments for physiologic components of MELD did not change this disparity. Region-specific disparities range from 3 to 7 pp, but in every allocation region, women are significantly less likely to be transplanted. When divided into gender-specific weight (height) quintiles higher BMI women are 2.4 pp (p=0.009) more likely to be transplanted than small men, but for every female weight quintile, the disparity in favor of men is monotonically increasing in male weight, and adjustments for size explain only 20% of the overall gender disparity in liver transplantation. (TABLE 1).
Conclusions: Our analysis of the UNOS STAR dismisses the hypothesis that the physiologic components of the MELD score alone explain the entirety of gender disparity. Recipient size plays a role in driving disparity, but the majority of the disparity remains unexplained. This leads us to conclude that there are some underlying social aspects affecting the allocation process that requires further elucidation. This is the first study to equitably evaluate and validate several hypotheses while quantifying their effects.

Adjusted Disparities within Gender Quintiles (* p<0.1, ** p<0.05, *** p<0.01)
Male Quintile 12345
FemaleQuintile 1-0.0022***-0.013**-0.071***-0.102***-0.114***-0.143***
20.013**-0.038***-0.063***-0.069***-0.101***
30.008-0.021***-045***-0.055***-0.080***
40.018**-0.013**-0.035***-0.047***-0.064***
50.024**-0.001-0.020**-0.037***-0.046***


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