Distance from VA Transplant Centers Affects Survival Rates for Liver Patients

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By Brenda L. Mooney

David Goldberg, MD, MSCE

David Goldberg, MD, MSCE

PHILADELPHIA — Where they live can be a life or death issue for veterans who have been deemed eligible for liver transplants, according to new research.

A study led by University of Pennsylvania researchers found that greater distance from a VA transplant center — or any transplant center — was associated with lower likelihood of being put on a wait list or receiving a transplant, and, consequently, a greater chance of death. Results of the study were published recently in the Journal of the American Medical Association.1

Background in the article discussed the pros and cons of the type of centralization instituted by the VA to manage costs, concentrate expertise and equalize quality of care issues across the nation. The study said it sought to determine whether increasing the distance between patients and treatment centers affected care delivery by looking at services such as organ transplantation.

In 2006, the Michael E. DeBakey VA Medical Center was one of the first VA medical facilities offering liver transplantation to veterans as an appropriate therapy for end-stage liver disease. In a photo from that time, David H. Berger, M.D., Operative Care Line executive (right) performed surgery with David Chafey, M.D., resident (left) and Kostas Votanopoulos, M.D., chief resident. Photo by Mike Lane, MEDVAMC Media Section

In 2006, the Michael E. DeBakey VA Medical Center was one of the first VA medical facilities offering liver transplantation to veterans as an appropriate therapy for end-stage liver disease. In a photo from that time, David H. Berger, M.D., Operative Care Line executive (right) performed surgery with David Chafey, M.D., resident (left) and Kostas Votanopoulos, M.D., chief resident. Photo by Mike Lane, MEDVAMC Media Section

At the time of the study, the VA had five transplantation centers (VATCs) nationwide offering liver transplants — in Houston; Nashville, TN; Pittsburgh, PA; Portland, OR; and Richmond, VA.

“Our study is the first to show that, while the VA model of centralized healthcare might serve to control costs, concentrate specialized expertise and minimize regional differences in the quality of care provided, it actually has negative consequences for many veterans,” said lead author David Goldberg, MD, MSCE. “Increased travel time to a transplant center likely prevents patients from being evaluated for transplantation, and thus ultimately making it onto the wait list.”

More Likely to Die

Results of the study indicated that veterans with liver disease who lived more than 100 miles from one of the VATCs are only half as likely to be placed on the liver transplant wait list to receive a new organ, and, the greater the distance, the more likely they were to die of liver disease.

“Among the subset that are wait-listed, increased distance is associated with decreased transplant rates, most likely because those patients at greater distances are unable to travel to the designated center quickly enough to receive a transplant after an organ becomes available,” Goldberg said. “Our findings show that this distance places patients who live far away at a disadvantage that may put their lives at risk.”

For the study, researchers linked data from the VHA’s electronic medical record to the Organ Procurement and Transplantation Network data to evaluate the association between distance from a VATC and wait-listing for liver transplantation, actually having a transplant and risk of death.

The study found that, from 2003 to 2010, 50,637 veterans were classified as potentially eligible for transplant. Of those, 6% were wait-listed for transplant — 49% of them on the list at one of the five VATCs. Using a variety of models, the researchers found that increasing distance to the closest VATC or any transplant center was associated with lower odds of being wait-listed; with lower transplantation rates and an increased risk of death.

For example, each doubling in distance from a local VA hospital to a VATC meant a 9% decreased likelihood of being wait-listed at a VATC, according to the results. With 7% of veterans within 100 miles being wait-listed, only 3% of those living farther away made it on the list.

The significant difference in wait-list rates persisted even when taking into consideration veterans who got on lists at non-VA transplant centers closer to their homes.

Among wait-listed veterans, proximity also appeared to be related to their chances of ultimately getting a transplant, with 64% living within 100 miles of that VA transplant center undergoing the surgery, compared with fewer than 55% of those living beyond 100 miles.

Living closer to a VATC also increased patients’ opportunities to serve as back-up recipients when the transplant for the original recipient fell through, according to the report.

As a result of all of those factors, five-year survival rates from diagnoses of end-stage liver disease were 58% for veterans living within a 100-mile radius of a VATC compared to less than 45% for those who live more than 300 miles away, according to the study.

 

Barriers to Care

Barriers to care, according to the authors, were long travel times from homes remote from a transplant center, which reduced the likelihood of getting evaluated for transplantation, and the difficulties in proceeding with transplants because of the need for the patients and/or their families to relocate.

“Patients wait-listed at a VA transplant center must relocate with a primary support person for at least one month post-transplant unless they live within reasonable driving distance, placing those without the resources or ability to relocate their family and/or a support person at a disadvantage,” said senior author, David Kaplan, MD, an assistant professor at the University of Pennsylvania and director of hepatology at the Philadelphia VAMC.

Many geographic disparities in healthcare, such as stroke or trauma care, are primarily issues in rural America, the authors pointed out. The current structure of the VA transplant system, however, greatly affects urban dwellers as well, they add.

As an example, the study noted that the closest VATC to New York City is 300 miles away in Pittsburgh, PA.

“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,” the authors emphasized. “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 study noted the opening of two new VA liver transplant centers in Madison, WI, and Miami but suggested that will not fully alleviate the issues related to geographic differences in transplantation availability.

Instead, the authors suggested greater use of telehealth to evaluate patients for inclusion on the transplant lists, deputizing local provider teams to perform initial wait-listing evaluations, streamlining referral to VA transplant centers, and lowering financial disincentives for access to local transplant services.

In addition, they called for more investigation of “the relationship between these findings and centralizing specialized care.”

1Goldberg DS, French B, Forde KA, Groeneveld PW, Bittermann T, Backus L, Halpern SD, Kaplan DE. Association of Distance From a Transplant Center With Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival Among US Veterans. JAMA. 2014;311(12):1234-1243. doi:10.1001/jama.2014.2520.

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