dressing these issues made this a challenging assignment, and the committee cautions that its findings must be considered provisional rather than conclusive.

The committee reviewed several articles that examine whether minorities have equal access to transplantation. Although almost all of these articles deal with kidney transplantation, the committee believes that some of the factors that bear on curtailed minority access to kidney transplants are also likely to bear on access to other solid organ transplants, although data on these issues are limited.

Lower access by African Americans to kidney transplantation is well documented (Alexander and Sehgal, 1998; Eggers, 1995). Much of the disparity appears to be due to the fact that African Americans are not placed on waiting lists as quickly, or in the same proportion, as their white counterparts. Moreover, once they are placed on a waiting list, African Americans do not receive kidney transplants as quickly as whites (Alexander and Sehgal, 1998; Eggers, 1995; DHHS, 1998c: Kasiske et al., 1991).

African Americans appear to fare somewhat better with respect to liver transplants than is the case with kidneys. Eckhoff and colleagues (1998) reviewed liver transplantation performed at the Alabama Organ Center and concluded that African Americans may experience a delay in referral to the center for evaluation or may not be referred at all, compared to the white population. However, they also concluded that once patients were referred, there were no racial disparities in being accepted onto the waiting list or in receiving a transplant. They suggested that access to health care, distrust of the medical community, lower socioeconomic status, and a lack of understanding about liver transplantation on the parts of both physicians and patients could be factors that influence the disparities in patient referrals. The DHHS Inspector General also found that the waiting times of African Americans for livers was quite similar to those of whites (DHHS, 1998c).

The committee's own analysis of waiting list data for 1995-1999 showed that for livers, African Americans comprised 8 percent of the list and received 9 percent of the transplants. These results indicate that the racial disparity in transplantation observed among patients on waiting lists for kidneys is not observed among patients waiting for livers. It does appear, however, that African Americans enter the list and receive liver transplants when they are sicker, relative to other racial groups. A greater percentage of African Americans are both listed and transplanted in status 1 (12 percent listed and 14 percent transplanted) relative to status 2 (10 percent listed and 8 percent transplanted) or status 3 (7 percent listed and 7 percent transplanted). The fact that African Americans are listed in disproportionately high numbers in status 1 reinforces the suggestion that initial access to health care and to referrals for transplant evaluation is an important impediment for African Americans with liver disease.

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