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.
Dr David Goldberg and colleagues from Philadelphia, USA evaluated 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.
The team performed a retrospective study of veterans meeting liver transplantation eligibility criteria from 2003 until 2010, using data from the Veterans Health Administration’s integrated, national, electronic medical record linked to Organ Procurement and Transplantation Network data.
The team's primary outcome was being waitlisted for transplantation at a VATC.
Secondary outcomes included being waitlisted at any transplant center, undergoing a transplantation, and survival.
From 2003-2010, 50,637 veterans were classified as potentially eligible for transplant.
|11% were waitlisted at any transplant center|
|Journal of the American Medical Association|
The team noted that 6% were waitlisted and 49% of those were waitlisted at 1 of the 5 VATCs.
Of 3417 veterans receiving care at a VA hospital located within 100 miles from a VATC,
The team observed that 7% were waitlisted at a VATC, and 11% at any transplant center.
Of 47,219 veterans receiving care at a VA hospital located more than 100 miles from a VATC, 3% were waitlisted at a VATC, and 5% at any transplant center.
In multivariable models, the researchers found that increasing distance to closest VATC was associated with significantly lower odds of being waitlisted at a VATC or any transplant center.
For example, the researchers found that a veteran living 25 miles from a VATC would have a 7% adjusted probability of being waitlisted, whereas a veteran 100 miles from a VATC would have a 6% adjusted probability.
In adjusted models, increasing distance from a VATC was associated with significantly lower transplantation rates.
The researchers found a significantly increased mortality among waitlisted veterans from the time of first hepatic decompensation event in multivariable survival models.
For example, a waitlisted veteran living 25 miles from a VATC would have a 63% 5-year adjusted probability of survival from first hepatic decompensation event compared with a 60% 5-year adjusted probability of survival for a veteran living 100 miles from a VATC.
Dr Goldberg and team conclude, "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."