A Statewide, Population-Based, Time Series Analysis of Access to Liver Transplantation1

Abstract

While the number of patients listed for liver transplant has increased, the pool of donor organs has remained constant. Questions have arisen regarding equitable access to organs. The purpose of this study was to analyze factors associated with access to liver transplantation (LT) using a large, population-based, hospital discharge database. The primary hypothesis was that a variety of factors other than medical need could be associated with access to LT. The rate of LT was defined as the number of liver transplants per admission for liver disease. The data sources were selected to allow a population-based, time-series analysis of all patients admitted with liver disease and those receiving liver transplants in all 157 nonfederal hospitals in North Carolina from 1988 to 1993. The hypotheses of this study were that age, gender, payment source, type of liver disease, distance from the transplant center, and rural county of residence were associated with patients' likelihood of access to LT. During the six years studied, 56,803 patients were admitted with liver disease and 126 underwent liver transplantation (LT). The rate of LT increased from 0.07% to 0.27%. Age, gender, source of payment, type of liver disease, rural county of residence, and distance of residence from the transplant center were associated with rates of transplantation. In the multivariate model, source of payment appeared to have the strongest association with the likelihood of LT. These findings raise important questions associated with equitable access to health care, need for physician education, and transplant center regionalization.

Greater travel time to a liver transplant center does not adversely affect clinical outcomes

“…No studies have captured detailed data on such patients, but such referral bias along urban vs. rural lines has been implied. 1,2,11 While MELD scores at time of referral were similar between groups, we did not examine change in MELD score, which may be predictive of mortality. 12,13 Perhaps nonreferred patients tend to be those in rapid decline, with MELD scores over 20 and rising.…”

“…1,2 Such data are based on national or state analyses of hospital admissions for potentially transplantable liver diseases. However, these studies examined transplant only without details about listing and suitability for transplant.…”

“…Referral disparities have been implied along geographic and racial lines and for U.S. veterans. 1,[3][4][5] Alternatively, distant patients may be less likely to successfully move through the transplantation process even after referral. While level of education and income have been examined in referred patients, 6 no studies have analyzed travel time.…”

Liver Transplant Waiting Time Does Not Correlate With Waiting List Mortality: Implications for Liver Allocation Policy

“…Source of insurance payment was the most important factor associated with liver transplantation rates. 8 For renal transplant candidates, data suggest that many of these same factors are associated with access to the renal transplant waiting list. 9 Evidence also suggests that many potentially appropriate candidates for liver transplantation with alcoholic liver disease are not referred to the transplant system.…”

Rates of Solid-Organ Wait-listing, Transplantation, and Survival Among Residents of Rural and Urban Areas

“…In a previous investigation of the impact of distance on liver transplantation using a single-state hospital discharge database, the rate of liver transplants per admission for liver disease for residents of counties more than 250 miles from a transplant center was 80% lower (PϽ.001) than for residents living in the county with a transplant center. 25 In a study from Ireland, the combination of residence remote from the transplant center and lack of private (no governmental option) health insurance was associated with markedly lower liver transplant access. 26 There was no disparity of access by insurance status among residents who lived near the transplant center.…”