Among veterans meeting eligibility for liver transplantation, greater distance from a Veterans Affairs transplant center or any transplant center was associated with lower likelihood of being put on a waitlist or receiving a transplant, and a greater likelihood of death, according to a study in the March 26 issue of JAMA.
Centralization of specialized health care services is used to control costs, concentrate expertise, and minimize regional differences in quality of care. Although efficient, centralization may offset gains in care delivery by increasing the distance between patients and hospitals. The effect of increased travel on access and outcomes for services such as organ transplantation is not fully understood, according to background information in the article.
David S. Goldberg, M.D., M.S.C.E., of the University of Pennsylvania, Philadelphia, and colleagues linked data from the Veterans Health Administration's electronic medical record to Organ Procurement and Transplantation Network data to evaluate the association between distance from a Veterans Affairs (VA) transplant center (VATC) and waitlisting for liver transplantation, actually having a transplant, and risk of death.
From 2003-2010, 50,637 veterans were classified as potentially eligible for transplant; 6 percent were waitlisted for transplant, and 49 percent of these veterans were waitlisted at 1 of the 5 VATCs. In various models, increasing distance to closest VATC or any transplant center was associated with lower odds of being waitlisted; with lower transplantation rates; and an increased risk of death.
The authors write that these findings may be explained by (1) long travel times from homes remote from a transplant center reducing the likelihood of getting evaluated for transplantation; or (2) reduced ability to proceed with transplantation because of the need for a patient or his or her family members to relocate.
"This issue of distance and access to care is critical given the focus on accountable care organizations that create large networks of physicians and hospitals. As complex, expensive medical technology evolves, certain services may only be offered at a limited number of sites. Although our findings are consistent with prior studies evaluating the association of distance to care, our study is the first, to our knowledge, to demonstrate the adverse consequences of centralization of specialized care at a limited number of sites," the researchers write.
"The relationship between these findings and centralizing specialized care deserves further investigation."
(doi:10.1001/jama.2014.2520; Available pre-embargo to the media at http://media.
Editor's Note: This work was supported in part by a Health Resources and Services Administration contract. The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.