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Original Investigation |

Association of Distance From a Transplant Center With Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival Among US Veterans

David S. Goldberg, MD, MSCE1,2,3; Benjamin French, PhD2,3; Kimberly A. Forde, MD, MHS1,2; Peter W. Groeneveld, MD, MS3,4,5; Therese Bittermann6; Lisa Backus, MD, PhD7; Scott D. Halpern, MD, PhD2,3,8; David E. Kaplan, MD, MSc1,9
[+] Author Affiliations
1Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia
2Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
4Division of General Internal Medicine, University of Pennsylvania, Philadelphia
5Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
6Department of Medicine, University of Pennsylvania, Philadelphia
7Department of Veterans Affairs/Office of Public Health, Philadelphia, Pennsylvania
8Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia
9Gastroenterology Section, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
JAMA. 2014;311(12):1234-1243. doi:10.1001/jama.2014.2520.
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Importance  Centralization of specialized health care services such as organ transplantation and bariatric surgery is advocated to improve quality, increase efficiency, and reduce cost. The effect of increased travel on access and outcomes from these services is not fully understood.

Objective  To evaluate the association between distance from a Veterans Affairs (VA) transplant center (VATC) and access to being waitlisted for liver transplantation, actually having a liver transplant, and mortality.

Design, Setting, and Participants  Retrospective study of veterans meeting liver transplantation eligibility criteria from January 1, 2003, until December 31, 2010, using data from the Veterans Health Administration’s integrated, national, electronic medical record linked to Organ Procurement and Transplantation Network data.

Main Outcomes and Measures  The primary outcome was being waitlisted for transplantation at a VATC. Secondary outcomes included being waitlisted at any transplant center, undergoing a transplantation, and survival.

Results  From 2003-2010, 50 637 veterans were classified as potentially eligible for transplant; 2895 (6%) were waitlisted and 1418 of those were waitlisted (49%) at 1 of the 5 VATCs. Of 3417 veterans receiving care at a VA hospital located within 100 miles from a VATC, 244 (7.1%) were waitlisted at a VATC and 372 (10.9%) at any transplant center (VATC and non-VATCs). Of 47 219 veterans receiving care at a VA hospital located more than 100 miles from a VATC, 1174 (2.5%) were waitlisted at a VATC and 2523 (5.3%) at any transplant center (VATC and non-VATCs). In multivariable models, increasing distance to closest VATC was associated with significantly lower odds of being waitlisted at a VATC (odds ratio [OR], 0.91 [95% CI, 0.89-0.93] for each doubling in distance) or any transplant center (OR, 0.94 [95% CI, 0.92-0.96] for each doubling in distance). For example, a veteran living 25 miles from a VATC would have a 7.4% (95% CI, 6.6%-8.1%) adjusted probability of being waitlisted, whereas a veteran 100 miles from a VATC would have a 6.2% (95% CI, 5.7%-6.6%) adjusted probability. In adjusted models, increasing distance from a VATC was associated with significantly lower transplantation rates (subhazard ratio, 0.97; 95% CI, 0.95-0.98 for each doubling in distance). There was significantly increased mortality among waitlisted veterans from the time of first hepatic decompensation event in multivariable survival models (hazard ratio, 1.03; 95% CI, 1.01-1.04 for each doubling in distance). For example, a waitlisted veteran living 25 miles from a VATC would have a 62.9% (95% CI, 59.1%-66.1%) 5-year adjusted probability of survival from first hepatic decompensation event compared with a 59.8% (95% CI, 56.3%-63.1%) 5-year adjusted probability of survival for a veteran living 100 miles from a VATC.

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

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Figure.
Geographic Distribution of VA Medical Centers (n = 128), Including 4 Transplant Centers, and Variation in Rates of Waitlisting for Liver Transplantation

The median proportion of veterans waitlisted at a VA transplant center (VATC) was 2.3% (interquartile range [IQR], 1.4%-3.7%), and waitlisted at any transplant center was 5.5% (IQR, 3.5%-6.7%). The median center-specific percentage of veterans waitlisted at a VATC relative to overall waitlistings was 54.3% (IQR, 35.1%-66.7%).

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