*Purpose: The path to liver transplant (LTX) typically begins with primary care providers(PCPs), and is dependent on timely referral to transplant centers. The referral patterns of PCPs in the state of Kentucky(KY) have considerable variability, reflecting upon the knowledge base and perceptions of providers on end-stage liver disease(ESLD) in the community. No validated survey exists to evaluate the knowledge and perceptions of referring providers towards transplantation. This study aims to identify knowledge gaps and perceptions of ESLD among PCPs.

*Methods: We conducted focus groups with PCPs in rural communities to create survey questions specific to knowledge, attitudes, beliefs regarding liver disease, and referral practices. The survey was generated and distributed widely to PCPs in KY. Data were collected based on a 5 point Likert agreement scale and multiple choice questions, and analyzed using descriptive statistics. Knowledge of and biases towards ESLD were analyzed by provider/practice type.

*Results: Of 332 surveys, we received 82(24.7%) responses. Most providers in KY were White (81.7%), male (59.8%), and in practice for 17.2(SD=12.8) years. Seventeen (20.7%) PCPs reported approximately 20% or greater of their daily practice consisting of managing patients with ESLD. While 47.6% PCPs stated that they would refer an ESLD patient to a gastroenterologist (GI), only 42.7% of providers reported knowing a referring GI practice that managed ESLD. Only 35.4% of PCPs knew the indications for liver transplantation, while 8.5% felt that alcohol induced cirrhosis was an absolute contraindication. Only 46.3% and 17.1% of PCPs would refer a patient for transplant evaluation without proven abstinence from alcohol or intravenous drugs, respectively. When stratified by practice type (internal vs family medicine), PCPs with internal medicine degrees were more likely to refer for liver transplant evaluation without proven periods of abstinence from alcohol (p=0.014). There was no difference in referral patterns between practice types with respect to abstinence from intravenous drug use. Regarding ESLD, 78.1% and 91.4% of PCPs felt that they should know the criteria for LTX and be involved in the LTX referral process, respectively. However, only 51.2% and 33.0% of PCPs felt capable of managing ESLD and responsible for directly referring a patient to a LTX center.

*Conclusions: Knowledge gaps surrounding ESLD, management, and LTX referral exist in community medicine practice. Furthermore, the lack of GI specialists in non-urban areas highlight the importance of ongoing education, resources, and facilitation of transplant referral access for PCPs, who are managing patients with ESLD.

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