Geography influences access to many specialized healthcare services. A CDC report demonstrated higher mortality among rural Americans for the five leading cause of death. This did not include liver disease. The mechanisms for these disparities are unknown, but may include physical barriers (i.e., distance traveled for specialized healthcare).

The management of patients with chronic liver failure (CLF) encompasses a spectrum of care: 1) managing complications of portal hypertension; 2) screening and treating hepatocellular carcinoma (HCC); and 3) caring for acutely ill inpatients. Liver disease management is superior when led by an expert in liver disease at a specialized center, almost always a LT center in a large urban community. For patients with CLF eligible for a liver transplant (LT), rural/urban status and distance to a LT center are associated with less waitlisting and transplantation. However, no population-based studies have evaluated the association between geographic isolation and survival in patients with CLF, important because fewer than 1 in 6 are waitlisted, and fewer than 1 in 12 is transplanted.