Access to heart and liver transplantation in the late 1980s

Because of a shortage of usable organs, many who require heart or liver transplants for survival will not have access to them. Access to care may reflect demographic factors and ability to pay, as well as medical considerations. Receipt of an organ may be influenced by expected survival with and without a transplant, age, gender, race, ability to pay, and distance to a transplant center. Discharge abstract data from a national sample of over 500 hospitals in 1986 and 1987 were used to select heart and liver recipients and others with end-stage diseases who did not receive a transplant. Multivariate logistic regression analyses were then used to estimate how receipt of a transplant was influenced by expected years of survival after transplantation (YAT), expected ability to pay, age, sex, race, and distance to a transplant center. Controlling for differences in expected YAT, age, sex, race, and distance to the transplant center, those expected to have the most ability to pay were more likely to receive heart and liver transplants, compared to those expected to have medium ability to pay. Third-party coverage was particularly important in receipt of a transplant for those with absolute contraindications. Expected YAT and age were significant, with some evidence of a tradeoff between urgency and expected YAT in the case of hearts. Men were more likely to obtain heart transplants and women were more likely to get liver transplants. The effects of distance were small. Existing regulatory incentives and biological, medical, and cultural reasons may justify the age-, sex-, race-, and prognosis-related differences in the odds of receiving a transplant. The importance of ability to pay may not have been adequately observed in previous studies restricted to the patients screened at major transplant centers. Hospital discharge records with personal identifiers, linkage to official waiting lists, and better patient level socioeconomic information would permit more definitive analysis.