Eligible patients who live farther away from a liver transplant center are less likely to be put on a waiting list, less likely to receive a transplant, and more likely to die within 5 years than are those who live closer, according to a report published online March 25 in JAMA.
These findings have broad implications beyond those for liver transplantation alone. "As complex, expensive medical technology evolves, certain services may be offered only at a limited number of sites" – an approach that may be more efficient but that increases the distance between patients and the centers at which they can receive care. "Our study is the first to demonstrate the adverse consequences of centralization of specialized care at a limited number of sites," said Dr. David S. Goldberg of the division of gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, and his associates.
Dr. David S. Goldberg
The researchers assessed the medical records of 50,637 patients who were active users of Veterans Affairs outpatient care and had decompensated cirrhosis or hepatocellular carcinoma; of these, 2,895 were wait-listed for liver transplantation during 2003 and 2012. Liver transplantation is offered at only five VA transplant centers, which are located in Houston; Nashville, Tenn.; Pittsburgh; Portland, Ore.; and Richmond, Va.
Patients who lived farther away from these five centers and from non-VA transplant centers were significantly less likely to be wait-listed than were those who lived closer. For example, 66% of veterans who lived within 100 miles of a liver transplant center were wait-listed, compared with less than 51% of those who resided farther away.
Once patients were on the list, they were significantly less likely to receive a liver transplant if they resided far from a transplant center. For example, 70.4% of patients who lived within 100 miles of a transplant center received a transplant, compared with only 58.8% of those who lived 101-200 miles away, 57.3% of those who lived 201-300 miles away, and 53.5% of those who lived 301-500 miles away.
Overall survival also decreased as distance from a liver transplant center increased. For example, a wait-listed patient living 25 miles from a transplant center had a 62.9% probability of survival 5 years from the first hepatic decompensation event, while one who lived 100 miles from a transplant center had a 59.8% probability of surviving 5 years from the first hepatic decompensation event, Dr. Goldberg and his associates wrote (JAMA 2014;311:1234-43).
Several health services including proton-beam therapy, bariatric surgery, and treatment for complex or rare cancers currently are offered at a limited number of sites or are preferentially reimbursed by insurers if they are treated at designated "centers of excellence." The results of this study demonstrate that such centralized care may have the unintended consequence of excluding patients who live farther from these centers from treatment, the investigators added.
This study was supported in part by the U.S. Health Resources and Services Administration. No financial conflicts of interest were reported.