title: Following the organ supply: assessing the benefit of inter-DSA travel in liver transplantation.
abstract: BACKGROUND
  Disparity in access to liver transplantation (LT) in the United States persists despite directives from the federal government to reduce geographic variation. We assessed the impact of socioeconomic status (SES) and traveling to alternative donation service areas (DSAs) on patient survival.
  
  
  METHODS
  A prospective cohort study integrating transplant registry and U.S. Census data was analyzed using multivariate linear Cox proportional hazards models. A separate matched-pairs analysis was used to assess the benefit of traveling on patient survival and transplantation rate.
  
  
  RESULTS
  High SES is associated with increased access to LT (adjusted hazard ratio [aHR], 1.05; 95% confidence interval [95% CI], 1.01-1.08) and reduced mortality after waitlisting (aHR [95% CI], 0.88 [0.85-0.93]). Increased access is mediated, in part, through inter-DSA travel. Travel was associated with high SES, white race, blood group O, private insurance, and residence in regions 1, 5, and 11. Transplant candidates in the highest SES quartile were approximately 70% more likely to travel (aHR [95% CI], 1.67 [1.43-1.97]) than those in the lowest SES quartile. Compared with matched control patients, travelers were 74% more likely to be transplanted (aHR [95% CI], 1.74 [1.56-1.94]) and 20% less likely to die after listing (aHR [95% CI], 0.79 [0.69-0.92]).
  
  
  CONCLUSIONS
  High SES and inter-DSA travel are strongly associated with increased LT access and reduced mortality. Travelers are more likely to be sociodemographically advantaged and privately insured and to live in regions with reduced access to deceased-donor organs.
authors.affiliation: Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA.
authors.forename: Nino
authors.initials: N
authors.lastname: Dzebisashvili
authors.forename: Allan B
authors.initials: AB
authors.lastname: Massie
authors.forename: Krista L
authors.initials: KL
authors.lastname: Lentine
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schnitzler
authors.forename: Dorry
authors.initials: D
authors.lastname: Segev
authors.forename: Janet
authors.initials: J
authors.lastname: Tuttle-Newhall
authors.forename: Sommer
authors.initials: S
authors.lastname: Gentry
authors.forename: Richard
authors.initials: R
authors.lastname: Freeman
authors.forename: David A
authors.initials: DA
authors.lastname: Axelrod
mesh_terms: D000017:ABO Blood-Group System; D000328:Adult; D001741:Black or African American; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D054625:Healthcare Disparities / Q000191:economics / Q000208:ethnology; D006630:Hispanic or Latino; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D016031:Liver Transplantation / Q000009:adverse effects / Q000191:economics / Q000208:ethnology / Q000401:mortality; D008297:Male; D016555:Matched-Pair Analysis; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012042:Registries; D012111:Residence Characteristics; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012959:Socioeconomic Factors; D013997:Time Factors; D014019:Tissue Donors / Q000600:supply & distribution*; D020858:Tissue and Organ Harvesting; D014195:Travel / Q000191:economics; D016896:Treatment Outcome; D014481:United States; D014850:Waiting Lists / Q000401:mortality; D044465:White People; D055815:Young Adult
chemical_list: D000017:ABO Blood-Group System