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Distance is associated with mortality on the waitlist in pediatric liver transplantation
Joel T Adler1, Yanik J Bababekov1, James F Markmann1
1Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
Insights
Longer travel distances to pediatric liver transplant centers increase waitlist mortality risk. While distance doesn't affect transplant time, it is linked to poorer outcomes for children needing transplants.
Area of Science:
- Pediatric Gastroenterology and Hepatology
- Transplant Surgery
- Public Health and Epidemiology
Background:
- Geographic distance to medical facilities can impact patient outcomes.
- Pediatric liver transplant recipients are a vulnerable population where access to care is critical.
Purpose of the Study:
- To investigate the association between distance to liver transplant centers and outcomes in pediatric patients.
- To determine if increased travel distance affects time to liver transplantation and waitlist mortality in children.
Main Methods:
- Utilized data from the Scientific Registry of Transplant Recipients (SRTR) for pediatric liver transplant registrants (under 18) from 2003-2012.
- Calculated distance from patient's home ZIP code to their listed transplant center.
- Employed competing events analysis, adjusting for demographic factors, indication, and Pediatric End-Stage Liver Disease (PELD) score.
Main Results:
- The median distance to a transplant center for 6924 children was 65 miles.
- Increased distance was not significantly associated with the time to liver transplantation (HR 0.99, P=.80).
- Longer distances were significantly associated with increased waitlist mortality (HR 1.75, P<.001).
Conclusions:
- Increasing geographic distance to pediatric liver transplant centers is associated with a higher risk of death while on the waitlist.
- This finding may indicate reduced access to essential specialist and tertiary care for children traveling longer distances.
- Transplant center volume influences patient travel distance, with larger centers attracting patients from farther away.
Abstract:
The distance to liver transplant centers affects outcomes in adult liver transplantation. Because pediatric patients are particularly vulnerable, we hypothesized that distance adversely affects the time to transplantation and waitlist mortality. The SRTR was queried for isolated pediatric liver transplant registrants (under age 18) with valid ZIP code information from 2003 to 2012. Distance was measured from home ZIP code to listing transplant center. Competing events analysis, adjusted for demographic factors, indication, and PELD, was undertaken for transplantation and death while on the waitlist. The median distance to listing transplant center for 6924 children was 65 (IQR 17.5-189) miles. Median distance traveled increased by listing volume (73.9 vs 33.8 miles, highest vs lowest volume quartile, P<.001 for trend) and varied across the country. Longer distance was not associated with time to transplantation (HR 0.99, longest vs shortest distance quartile, P=.80), but was associated with increased mortality (HR 1.75, P<.001). Larger centers attract patients from a distance, while smaller centers serve local populations. Increasing distance is associated with a higher risk of waitlist death, which may reflect decreased access to specialist and tertiary care associated with a transplant center.
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