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. 2022 Jul 28;28(12):1841–1856. doi: 10.1002/lt.26532

TABLE 4.

Summary table of themes about potential mechanisms for racial and ethnic inequities in liver transplant evaluation organized based on a conceptual framework of a systems engineering approach to improving equity in liver transplant evaluation

External environment
  • Structural racism propagated through ambiguous listing guidelines

  • Insurance‐related policies and national transplant metrics not aligned with equity

Process
Transplant center and local health system
  • Limited social worker resources (W)
  • Limited resources for non–English‐speaking patients (W)
People
  • Patient with low socioeconomic status (W)
  • Patient with low health literacy (W)
  • Barriers due to where patient lives or transportation access (W)
  • Support system/caregiver(s) with low socioeconomic status (W)
  • Support system/caregiver(s) with low health literacy (W)
  • Unreliable transportation from support system/caregiver (W)
  • Limited transplant team diversity (C)
  • Nonstandardized use of social worker in psychosocial assessment (C)
Tasks of patient, support, and care professionals
  • Variable patient engagement in the complex process (W)
  • Barriers to building trust in the patient–provider relationship (W)
  • Adaptability required by providers during assessments and education of patients (W)
  • Subjectivity and inconsistency in decision making (C)
  • Implicit bias and personally mediated racism in decision making (C)
Tools and technology
  • Reliance on information propagated through EHR (W)
  • Limited access to technology inhibits communication (W)
Adaptation
  • Limited review or awareness of transplant center outcomes related to equity

  • Limited team member feedback

  • Unclear transplant center role/ability to address disparities

Note: The conceptual framework was guided by the qualitative data and from the SEIPS 2.0 model.[ 23 ] Themes were identified through semistructured interviews and ethnographic observations at two urban transplant centers.

Abbreviations: C, committee meeting phase of process; EHR, electronic health record; LT, liver transplantation; SEIPS, Systems Engineering Initiative for Patient Safety; W, workup phase of process.