Accountability for end-stage organ care: implications of geographic variation in access to kidney transplantation.
BACKGROUND
The provision of effective surgical care for end-stage renal disease (ESRD) requires efficient evaluation and transplantation. Prior assessments of transplant access have focused primarily on waitlisted patients rather than the overall populations served by "accountable" providers of transplant services.


METHODS
Novel transplant referral regions (TRRs) were defined using United Network for Organ Sharing registry data for 301,092 kidney transplant listings to assign zip codes to "accountable" transplant programs. Subsequently, risk-adjusted observed to expected (O:E) rates of listing and transplant procedures were calculated for each TRR. Finally, the impact of variation in TRR listing and transplant rates on mortality was assessed for ESRD patients <60 years old diagnosed between 2000 and 2008.


RESULTS
In total, 113 TRRs were defined, 51% of which included >1 transplant center. The likelihood of being evaluated and listed for transplant varied significantly between TRRs (risk-adjusted O:E, 0.58-1.95). Variation was greater for the overall transplant rate (0.62-2.19), living donor transplantation (0.36-3.08), and donation after cardiac death transplant (0-15.4) than for standard criteria donors (0.64-2.86). Mortality was decreased for ESRD patients living in TRRs in the highest tertile of listings (hazard ratio, 0.89; P < .0001) and transplantation (0.90; P < .0001).


CONCLUSIONS
Residence in a TRR with care delivery systems that increase access to transplant services is associated with significant, risk-adjusted decreases in ESRD-related mortality. Transplant centers should continue to focus on improving access to care within the communities they serve.
Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH. Electronic address: david.a.axelrod@hitchcock.org.
David A
DA
Axelrod
St. Louis University Center for Outcomes Research, St. Louis University, St. Louis, MO.
Krista L
KL
Lentine
St. Louis University Center for Outcomes Research, St. Louis University, St. Louis, MO.
Huiling
H
Xiao
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
Thomas
T
Bubolz
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
David
D
Goodman
Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Richard
R
Freeman
St. Louis University Center for Outcomes Research, St. Louis University, St. Louis, MO.
Janet E
JE
Tuttle-Newhall
St. Louis University Center for Outcomes Research, St. Louis University, St. Louis, MO.
Mark A
MA
Schnitzler
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D005843:Geography; D006297:Health Services Accessibility; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D016030:Kidney Transplantation; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D012042:Registries; D012941:Social Responsibility; D015996:Survival Rate; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000379:methods*; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists; D055815:Young Adult