1. The greater the distance between the patient’s local Veterans Affairs (VA) hospital and Veterans Affairs Transplant Center (VATC), the less the likelihood of receiving a transplant when indicated.
2. Of those waitlisted, the survival rate was less for those who lived further than those who lived closer to the VATC.
Evidence Rating Level: 2 (Good)
Study Rundown: Healthcare centralization is necessary among highly specialized services such as liver transplantation resulting in difficulty for patients in often more rural areas. This study examined the relationship of distance between a VA (Veterans Affairs) hospital and VATC (Veterans Affairs Transplant Center). Veterans who were eligible for liver transplant were evaluated between 2003 and 2010 to identify those who were waitlisted and the relationship to their distance to VA transplant centers (VATC) and their distance to non-VA transplant center. In addition, the mortality was evaluated in relationship to this. The study found that with increasing distance to the VATC, there was a decrease likelihood of being placed on a waitlist. When looking at non-VA transplant centers, the trend was the same with a decreased likelihood of being placed on a waitlist with increasing distance. Furthermore, there was significantly increased mortality associated with increased distance from VATC (i.e., those living 25 miles away had a greater probability of survival than those who lived 100 miles away). The strengths of this study are the accessibility to VA records and a direct estimate could be made, whereas previous studies relied on hypothetical cohorts. The biggest limitation in this study is its inability to comment on other factors that may have contributed to the waitlist including psychosocial contraindications, hepatocellular carcinoma stage and possible VATC preferences. Nevertheless, this study argues that a there is a need for further investigation into centralizing specialized care.
Relevant Reading: Geographic inequity in access to livers for transplantation
In-Depth [retrospective cohort]: This study examined 50,637 veterans who were active users of the VA system from 2003-2010 and who were eligible for liver transplant and the relationship between the distance between the veteran’s home VA hospital and the VATC and/or any transplant center. For less than 100 miles, the percentage of veterans waitlisted at VATC was 7.1% compared to 10.9% at any center. For those located more than 100 miles from a VATC, 2.5% were waitlisted at a VATC compared to 5.3% at any transplant center. As distance increased, the percentage waitlisted decreased (p < 0.001). In addition, there was an increase in risk of mortality as distance from VA hospital to VATC increased (HR 1.03, 95% CI, 59.3%-63.1%).
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