title: Local access to subspecialty care influences the chance of receiving a liver transplant.
abstract: Prior studies have examined the impact of demographic factors on liver transplant outcomes. These factors may be surrogate markers for access to medical care. We investigated physician density in referred patients' hospital service areas (HSAs) as a factor in patients' probability of receiving a liver transplant. We performed a retrospective review of patients referred for liver transplantation from 2002 through 2010. Data on physician density were obtained from the Dartmouth Atlas of Health Care. The primary outcome was the receipt of a liver transplant. A Cox hazard analysis was used to control for various demographic and medical covariates. Over the time period, 1485 adult patients were considered for liver transplantation. Factors that influenced the hazard of receiving a liver transplant were the Model for End-Stage Disease (MELD) score at referral {Hazard ratios (HR) per point = 1.11 [95% confidence interval (CI) = 1.09-1.14]}, a secondary diagnosis of hepatocellular carcinoma [HR = 2.72 (95% CI = 1.76-4.20)], blood group AB [HR = 2.98 (95% CI = 1.52-5.87) with blood group A as the referent], the type of insurance [HR for Medicare = 0.36 (95% CI = 0.14-0.89) with commercial insurance as the referent], and the number of gastroenterologists in an HSA [odds ratio with each additional gastroenterologist per 100,000 population = 1.12 (95% CI = 1.01-1.25)]. Age, race, sex, distance to the transplant center, and residence in a rural community did not influence the chance of receiving a liver transplant. In conclusion, the hazard of receiving a liver transplant are influenced by the diagnosis, MELD score, and insurance status; in addition, patients were 12% more likely to receive a transplant with each additional gastroenterologist per 100,000 population in their local HSA. Local access to gastroenterology subspecialty care is an important factor in receiving a liver transplant.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill 27599-7584, USA. barritt@med.unc.edu
authors.forename: A Sidney
authors.initials: AS
authors.lastname: Barritt
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Telloni
authors.forename: Clarence W
authors.initials: CW
authors.lastname: Potter
authors.forename: David A
authors.initials: DA
authors.lastname: Gerber
authors.forename: Paul H
authors.initials: PH
authors.lastname: Hayashi
mesh_terms: D000328:Adult; D005260:Female; D005762:Gastroenterology; D006297:Health Services Accessibility; D006305:Health Status Indicators; D054625:Healthcare Disparities; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D008107:Liver Diseases / Q000175:diagnosis / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009657:North Carolina; D016017:Odds Ratio; D018579:Patient Selection; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D012111:Residence Characteristics; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014850:Waiting Lists