title: The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes.
abstract: OBJECTIVE
  Variation in kidney transplant access across the United States may motivate relocation of patients with ability to travel to better-supplied areas.
  
  
  METHODS
  We examined national transplant registry and U.S. Census data for kidney transplant candidates listed in 1999 to 2009 with a reported residential zip code (n = 203,267). Cox's regression was used to assess associations of socioeconomic status (SES), distance from residence to transplant center, and relocation to a different donation service area (DSA) with transplant access and outcomes.
  
  
  RESULTS
  Patients in the highest SES quartile had increased access to transplant compared with those with lowest SES, driven strongly by 76% higher likelihood of living donor transplantation (adjusted hazard ratio [aHR] 1.76, 95% confidence interval [CI] 1.70 to 1.83). Waitlist death was reduced in high compared with low SES candidates (aHR 0.86, 95% CI 0.84 to 0.89). High SES patients also experienced lower mortality after living and deceased donor transplant. Patients living farther from the transplant center had reduced access to deceased donor transplant and increased risk of post-transplant death. Inter-DSA travel was associated with a dramatic increase in deceased donor transplant access (HR 1.94, 95% CI 1.88 to 2.00) and was predicted by high SES, white race, and longer deceased-donor allograft waiting time in initial DSA.
  
  
  CONCLUSIONS
  Ongoing disparities exist in kidney transplantation access and outcomes on the basis of geography and SES despite near-universal insurance coverage under Medicare. Inter-DSA travel improves access and is more common among high SES candidates.
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hampshire, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Axelrod
authors.forename: Nino
authors.initials: N
authors.lastname: Dzebisashvili
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schnitzler
authors.forename: Paolo R
authors.initials: PR
authors.lastname: Salvalaggio
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
authors.forename: Sommer E
authors.initials: SE
authors.lastname: Gentry
authors.forename: Janet
authors.initials: J
authors.lastname: Tuttle-Newhall
authors.forename: Krista L
authors.initials: KL
authors.lastname: Lentine
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012923:Social Class; D014195:Travel; D016896:Treatment Outcome
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