Effects of rural status on health outcomes in pediatric liver transplantation: A single center analysis of 388 patients

Abstract

Rural status of patients may impact health before and after pediatric LT. We used UI codes published by the USDA to stratify patients as urban or rural depending county residence. A total of 388 patients who had LT and who met criteria were included. Rejection, PTLD, and survival were used as primary outcome measures of post-LT health. UNOS Status 1 and PELD/MELD scores >20 were used as secondary outcome measures of poorer pre-LT health. Logistic regression models were run to determine associations. We did not find any statistically significant differences in pre- or post-LT outcomes with respect to rurality. Among rural patients, there was a general trend for decreased incidence of rejection (25.0% vs. 33.4%; OR 0.64, 95% CI 0.29-1.44), increased risk of PTLD (5.6% vs. 3.4%; OR 1.86, 95% CI 0.36-3.31), and decreased survival (OR 0.85, 95% CI 0.34-2.13) after LT. Rural patients also tended to be sicker at the time of LT than patients from urban areas, with increased proportion of Status 1 (OR 1.17, 95% CI 0.51-2.70) and PELD/MELD scores >20 (OR 1.20, 95% CI 0.59-2.45). From a single center experience, we conclude that rurality did not significantly affect health outcomes after LT, although a larger study may validate the general trends that rural patients may have decreased rejection, increased PTLD, and mortality, and be in poorer health at the time of LT.

A systematic review of social determinants of health in pediatric organ transplant outcomes

“…66,88 However, in adjusted analyses, another study found rural patients were less likely to experience rejection but also less likely to survive at 5-year follow-up. 98 There were no significant differences in acute rejection or graft survival based on geographical remoteness in Australia and New Zealand. 59 However, remoteness of residence was the only predictor of mortality or re-transplantation among Australian children of Aboriginal and Torres Strait Islander Identity.…”

“…Two studies comparing outcomes across urban or rural residences found no significant difference in adherence or graft failure risk 66,88 . However, in adjusted analyses, another study found rural patients were less likely to experience rejection but also less likely to survive at 5‐year follow‐up 98 . There were no significant differences in acute rejection or graft survival based on geographical remoteness in Australia and New Zealand 59 .…”

Distance is associated with mortality on the waitlist in pediatric liver transplantation

“…This is particularly troubling for pediatric patients with end‐stage liver disease because the independent effect of UNOS region on waitlist survival and transplantation is likely exacerbated by the much smaller number of pediatric liver transplant centers. While a single‐center study did not find a significant association with rural areas and post‐transplant outcomes, a registry‐based study found differences only at 6 months with acute rejection . These studies underline the importance of understanding whether and how distance affects access to pediatric liver transplantation to determine whether potential targets for intervention, such as additional education, services, and support, can overcome distance barriers.…”

Relating multidimensional deprivation index to adherence outcomes in pediatric solid organ transplant.

“…The UI code, a measure of how rural or urban a county is, was included as a covariate given published research documenting disparities in transplant-related health by proximity to metropolitan areas (Park et al, 2011). UI codes are assigned by the United States Department of Agriculture and range from 1 to 12, with one representing large metropolitan areas and 12 representing rural areas smaller than 2,500 residents not adjacent to a metropolitan area (United States Department of Agriculture, 2019).…”