Veterans Living a Greater Distance from VA or Any Transplant Centers May have Less Chance of Receiving Liver Transplant
BACKGROUND:
Centralization of specialized healthcare services such as organ transplantation and bariatric surgery has been utilized to improve quality, increase efficiency, and reduce cost. The VA National Transplant Program centralizes liver transplantation at five VA transplant centers (VATCs): Houston, TX; Nashville, TN; Pittsburgh, PA; Portland, OR; and Richmond, VA. While veterans with secondary insurance (i.e. Medicare) may access either VA or non-VA transplant services, those with VA insurance alone may only access a VATC, except in rare emergencies. This retrospective, observational study evaluated the association between distance from a VATC and access to wait-listing and liver transplantation, as well as mortality. Using VA data, investigators identified 50,637 Veterans who met liver transplantation criteria from 1/03 through 12/10. The start date was chosen to allow for approximately one year after implementation of the current Model for End-Stage Liver Disease (MELD) allocation system, which prioritizes waitlist candidates based on severity of illness rather than waiting time. Investigators also restricted the cohort to Veterans adequately connected to VA outpatient care (at least two outpatient visits in the year following initial hepatic decompensation or cancer event) to ensure access to transplant referral.
FINDINGS:
- Among VA patients meeting eligibility criteria for liver transplantation, greater distance from a VATC or any transplant center was associated with lower likelihood of wait-listing or transplantation, and greater likelihood of death.
- Of the 50,637 Veterans classified as potentially transplant-eligible during the study period, 2,895 (6%) were waitlisted, with 1,418 (49%) at a VATC and 1,477 (51%) at a non-VATC. Overall, 7% of Veterans at a VA medical center ≤100 miles from a VATC were waitlisted at a VATC, and 11% at any transplant center, compared with 3% and 5%, respectively, living >100 miles from a VATC.
- Three-year survival from first hepatic decompensation event for waitlisted Veterans differed by distance: 72% (≤100 miles from VATC) vs 66% (>100 miles). Moreover, in multivariable survival models, increasing distance to a VATC was associated with significantly increased risk of mortality, with a 3% increased risk of mortality for every doubling of distance from local VAMC to VATC.
LIMITATIONS:
- As with any observational study, there may have been unmeasured confounding variables, including Veterans who were closer to a VATC having had more severe liver disease.
- Study participants were identified using ICD-9 codes rather than chart review, thus some patients may have been ineligible for transplant due to factors not noted in recorded diagnoses (for example, active substance abuse).
- Results may have been related to factors beyond distance, such as a VATC's preference for wait-listing patients from their particular center.
AUTHOR NOTE:
The effect of distance-based reduced access to centralized specialty care services is not specific to VA and, in fact, is a phenomenon likely more pronounced in the private sector.
Goldberg D, French B, Forde K, Groeneveld P, Bittermann T, Backus L, Halpern S, and Kaplan D. Association of Distance from a Transplant Center with Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival. JAMA. March 26, 2014;311(12):1234-43.
