Structural determinants of regional lung transplant listing rates in metropolitan France: a national ecological panel study
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Published on: August 15, 2022
Kinan El Husseini1, Jérôme Le Pavec2, Mathilde Salpin3
1INSERM, UMR 1149, Centre de recherche sur l'inflammation, Université Paris Cité, Paris, France; Service de Pneumologie, et Transplantation Pulmonaire, AP-HP, Hôpital Bichat, Paris, France.
Background:
Regional lung transplant listing rates in metropolitan France range from 2.4 to 11.4 new listings per million inhabitants per year across individual region-years, and from 4.7 to 8.3 when averaged over 2016-2023. We examined how geographic access, chronic respiratory disease burden, pulmonologist workforce composition, and socioeconomic deprivation relate to new waitlist inscriptions.
Methods:
Ecological panel study of 12 metropolitan French regions (2016-2023; 96 region-years). The outcome was annual new lung transplant listings per million inhabitants. Predictors were population-weighted distance to the nearest authorised transplant centre (and binary centre presence), office-based and hospital-salaried pulmonologist density, chronic respiratory disease prevalence, and the European Deprivation Index (EDI). We used pooled ordinary least squares with year fixed effects, Driscoll-Kraay (DK) and small-sample cluster-robust standard errors.
Results:
In the primary model, listing rates were higher with transplant programme presence (β = +0.86 listings/million/year; 95% DK CI 0.53-1.20), hospital-salaried pulmonologist density (β = +0.066; 95% DK CI 0.02-0.11), and lower socioeconomic deprivation (EDI β = -0.085; 95% DK CI -0.15 to -0.02). Office-based pulmonologist density was associated with listing rates unadjusted but attenuated after adjustment for centre presence, consistent with geographic co-location. With cluster-robust standard errors accounting for correlation within regions, the estimates were unchanged but all confidence intervals included zero.
Conclusions:
Inequalities in access to lung transplant listing in France may be in part driven by transplant programme distance, limited hospital-embedded pulmonology, and socioeconomic deprivation. These structural barriers are likely shared by other centralised, single-payer transplant systems. Additional studies using patient-level data to confirm these findings are needed to support interventions targeting these mechanisms.
