Does distance between home and transplantation center adversely affect patient outcomes after heart transplantation?
BACKGROUND
The emergence of heart transplantation referral centers, in an era of cost-conscious managed care programs, frequently leads to long-distance patient consultation and care. The purpose of this project was to review one center's experience regarding the effect of long distances from home to transplantation hospital on outcomes.


METHODS
Three hundred twelve adult, noninternational, transplant recipients surviving at least 3 months were assessed for 10 events: rejection episodes, number of endomyocardial biopsies, emergency department visits, hospital admissions, return to full-time work or school, infections, coronary allograft vasculopathy, malignancies, retransplantation, and death. Presence of a locally involved physician was also determined. Distance from the transplantation center was analyzed in three discrete groups: 0 to 150 miles (n = 207), 151 to 300 miles (n = 69), and >300 miles (n = 36).


RESULTS
There were no differences among the groups in mean length of follow-up (40.6, 36.9, 39.0 months, p = 0.27) or number of biopsies (20.5 +/- 0.16, 18.3 +/- 1.1, 18.0 +/- 1.1, p = 0.07). As the distance increased from the transplantation center, there was no greater incidence of adverse outcomes. Cellular rejection was the same among the groups (45%, 45%, 36%, p = 0.58). Likewise, emergency department visits and hospital admissions also did not vary: (9.7%, 5.8%, 8.3%, p = 0.61) and (22.2%, 13.0%, 16.7%, p = 0.23, respectively). There were no differences in the incidence of coronary vasculopathy (9.2%, 11.6%, 13.9%, p = 0.63). More importantly, the three groups did not differ in death/retransplantation rates (3-year survival, 84.5, 94.0 and 86.9, p = 0.14). Patients cared for by a local physician in addition to their transplant cardiologist had better survival rates than patients without a local physician (3-year survival rate, 90.7 vs 72.6, p = 0.0008).


CONCLUSIONS
Long-distance management of heart transplant recipients is successful and is not associated with an increase in adverse outcomes. By itself, distance should not represent a contraindication to transplantation. Patients should be encouraged to maintain contact with a local physician, in addition to the regularly scheduled visits at the transplantation center.
Rodkey
S M
SM
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
Hobbs
R E
RE
Goormastic
M
M
Young
J B
JB
D000293:Adolescent; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D016027:Heart Transplantation / Q000009:adverse effects; D006801:Humans; D015994:Incidence; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010343:Patient Admission; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012017:Referral and Consultation; D012086:Reoperation; D016019:Survival Analysis; D014195:Travel