*Purpose: In rural America, the road to obtaining a liver transplant (LTX) often starts at the primary care provider’s (PCP) office. Patients in rural communities have the lowest rates of wait-listing and experience higher mortality while awaiting LTX. There is significant variability in patient selection, timing, and discussion of LTX referral among PCPs. Data regarding the practice patterns around LTX referral, especially in rural populations, are limited. This qualitative study identifies issues related to knowledge and perceptions that hinder LTX referral among PCPs in Kentucky where 70% of counties are rural.

*Methods: Data were collected through audio-recorded focus groups within 4 different PCP practices in Kentucky. The transcripts underwent qualitative analyses to identify themes regarding barriers to LTX referral and perceptions of patients with end-stage liver disease (ESLD).

*Results: Three major thematic areas were identified that contributed to barriers and perceptions of PCPs towards LTX referral. Medical culture was a significant barrier, including beliefs that referrals were “not [being] my job [as a PCP]⋯ because that’s not how the hierarchy works.” Secondly, all focus groups identified gaps in knowledge regarding the diagnosis of liver disease, liver transplant eligibility, and knowledge of the transplant process as significant barriers. Finally, the most prevalent theme demonstrated a predisposition against referring patients with “self-induced causes of cirrhosis”, such as alcoholism or hepatitis B/C. PCPs stated that they “would not waste a liver” on this patient population because they would “destroy that one.” Although some PCPs said they had referred patients in the past, they asserted that “the bad patients don’t go to them [appointments at transplant centers].” Furthermore, PCPs expressed a belief that patients with “self-induced causes of cirrhosis” had to prove to the PCP that they were “worth that liver.” PCPs admitted to assigning arbitrarily defined targets such as attending regular PCP appointments and adhering to varying durations of abstinence from substance use. PCPs seemed to view these targets as evidence that the patient was “serious about [LTX]” prior to providing a referral.

*Conclusions: This study identifies several areas where perceptions of PCPs can serve as barriers to LTX access. These results suggest significant bias amongst PCPs and provides a foundation for future quantitative studies, educational opportunities and interventions to improve this healthcare disparity in rural communities.

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