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Increased Distance Reduces Likelihood of Liver Transplant

Living and receiving health care further away from a transplant center was associated with lower chances of being wait-listed for or receiving a liver transplant, according to a study of U.S. veterans described in the March 26 edition of JAMA.

Living further away from a transplant center was associated with lower chances of being wait-listed for or receiving a liver transplant, according to a study of U.S. veterans described in the March 26 edition of JAMA.

An nationwide Organ Procurement and Transplantation Network (OPTN) administered by the United Network for Organ Sharing (UNOS) has been established in an effort to make allocation of donated organs more fair, but disparities remain based on factors such as demographics and socioeconomic status.

Some regions of the country have longer donor organ wait-lists than others. People awaiting a transplant must live close enough to a transplant center -- or be able to move near one temporarily -- so they can reach the center within hours after a suitable donated organ becomes available. It is possible for people to get themselves listed at multiple centers in more than one region, but this can greatly increase the cost.

David Goldberg from the University of Pennsylvania and colleagues evaluated the association between distance to a transplant center and being wait-listed for liver transplantation, actually undergoing a liver transplant, and mortality, looking at how far U.S. veterans lived from one of the 5 Veterans Affairs (VA) transplant centers.

This retrospective analysis included more than 50,000 veterans classified as potentially eligible for a liver transplant between January 2003 and December 201, linking data from the Veterans Health Administration’s integrated national electronic records database to OPTN data.

Several conditions can damage the liver enough to require a transplant, with chronic hepatitis B or C and prolonged heavy alcohol use being among the most common.

Results

• Of the 50,637 veterans classified as potentially eligible for liver transplantation, 2895 (6%) were wait-listed anywhere, and 1418 (49%) of those were wait-listed at a Veterans Affairs transplant center.
• Among 3417 veterans receiving care at VA hospitals located within 100 miles of a VA transplant center, 244 (7.1%) were wait-listed at a VA transplant center and 372 (10.9%) were listed at any transplant center.
• Among 47,219 veterans getting care at VA hospitals located more than 100 miles from a VA transplant center, 1174 (2.5%) were waitlisted at a VA transplant center and 2523 (5.3%) were listed at any transplant center.
• In a multivariate analysis, increasing distance to the closest VA transplant center was associated with significantly lower odds of being wait-listed at a VA transplant center (odds ratio [OR] 0.91 for each doubling in distance).
• The odds of being wait-listed at any transplant center also fell with increasing distance from a VA transplant center (OR 0.94 for each doubling).
• In adjusted models, increasing distance from a VA transplant center was also associated with significantly lower odds of actually receiving a transplant (hazard ratio [HR] 0.97 for each doubling in distance).
• In addition, there was a small but significant increase in mortality with greater distance from a VA transplant center among wait-listed veterans from the time of their first hepatic decompensation or liver failure event (hazard ratio 1.03 for each doubling).

For example, the researchers wrote, "a veteran living 25 miles from a VA transplant center would have a 7.4%...adjusted probability of being wait-listed, whereas a veteran 100 miles from a VA transplant center would have a 6.2% ...adjusted probability." Further, "a waitlisted veteran living 25 miles from a VA transplant center would have a 62.9%...5-year adjusted probability of survival from first hepatic decompensation event compared with a 59.8%...5-year adjusted probability of survival for a veteran living 100 miles from a VA transplant center."

"Among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VA transplant center or any transplant center was associated with lower likelihood of being waitlisted, receiving a liver transplant, and greater likelihood of death," they concluded. "The relationship between these findings and centralizing specialized care deserves further investigation."

4/4/14

Reference

DS Goldberg, B French, KA Forde, et al. Association of Distance From a Transplant Center With Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival Among US Veterans. JAMA 311(12):1234-1243. March 26, 2014.