US Population Size and Outcomes of Adults on Liver Transplant Waiting Lists.

IF 10.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL
Tomohiro Tanaka, George Wehby, Mark Vander Weg, Keith Mueller, David Axelrod
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引用次数: 0

Abstract

Importance: Disparities in organ supply and demand led to geographic inequities in the score-based liver transplant (LT) allocation system, prompting a change to allocation based on acuity circles (AC) defined by fixed distances. However, fixed distances do not ensure equivalent population size, potentially creating new sources of disparity.

Objective: To estimate the association between population size around LT centers and waiting list outcomes for critically ill patients with chronic end-stage liver disease and high Model for End-stage Liver Disease (MELD) scores or acute liver failure (ALF).

Design, setting, and participants: This US nationwide retrospective cohort study included adult (aged ≥18 years) candidates for deceased donor LT wait-listed between June 18, 2013, and May 31, 2023. Follow-up was completed June 30, 2023. Participants were divided into pre-AC and post-AC groups.

Exposure: Population size within defined radii around each LT center (150 nautical miles [nm] for participants with high MELD scores and 500 nm for those with ALF) based on AC allocation policy.

Main outcomes and measures: LT candidate waiting list mortality and dropout rate were analyzed using generalized linear mixed-effect models with random intercepts for center and listing date before and after AC implementation. Fine-Gray competing risk regression, accounting for clustering, was used as a secondary model.

Results: The study analyzed 6142 LT candidates (1581 with ALF and 4561 with high MELD scores) during the pre-AC era and 4344 candidates (749 with ALF and 3595 with high- MELD scores) in the post-AC era, for a total of 10 486 participants (6331 male [60.5%]; mean [SD] age, 48.5 [7.1] years). In the high-MELD cohort, being listed at a center in the lowest tertile of population size was associated with increased waiting list mortality in the AC era (adjusted odds ratio [AOR], 1.68; 95% CI, 1.14-2.46). Doubling of the population size was associated with a 34% reduction in the odds of mortality or dropout (AOR, 0.66; 95% CI, 0.49-0.90). These results were consistent with those of the extended Fine-Gray models and were also corroborated by multiple sensitivity analyses. However, there were no significant population density-associated disparities in the ALF cohort.

Conclusions and relevance: In this retrospective nationwide cohort study, being wait-listed in less populated regions was associated with greater mortality among critically ill LT candidates with high MELD scores, underscoring the limitations of allocation systems based purely on fixed distances.

重要性:器官供需的差异导致基于评分的肝移植(LT)分配系统在地理位置上的不公平,促使人们改用基于固定距离界定的敏锐度圈(AC)进行分配。然而,固定距离并不能确保同等的人口规模,从而可能造成新的差异:目的:估计LT中心周围人口规模与慢性终末期肝病、终末期肝病模型(MELD)评分高或急性肝衰竭(ALF)重症患者候诊结果之间的关系:这项美国全国范围的回顾性队列研究纳入了2013年6月18日至2023年5月31日期间候选的成人(年龄≥18岁)死亡供体LT患者。随访于 2023 年 6 月 30 日结束。参与者被分为先天性心脏病组和后天性心脏病组:根据 AC 分配政策,每个 LT 中心周围规定半径内的人口数量(MELD 评分高的参与者为 150 海里 [nm],ALF 患者为 500 海里):采用广义线性混合效应模型分析了LT候选者等待名单上的死亡率和辍学率,并对AC实施前后的中心和挂牌日期进行了随机截距。作为次要模型,使用了考虑聚类的 Fine-Gray 竞争风险回归:研究分析了前 AC 时代的 6142 名 LT 候选者(1581 名 ALF 患者和 4561 名高 MELD 评分患者)和后 AC 时代的 4344 名候选者(749 名 ALF 患者和 3595 名高 MELD 评分患者),共计 10 486 名参与者(6331 名男性 [60.5%];平均 [SD] 年龄 48.5 [7.1] 岁)。在高MMELD队列中,被列入人口规模最低三分位数的中心与AC时代候诊死亡率的增加有关(调整赔率比[AOR],1.68;95% CI,1.14-2.46)。人口数量增加一倍与死亡率或辍学几率降低 34% 有关(AOR,0.66;95% CI,0.49-0.90)。这些结果与扩展的 Fine-Gray 模型的结果一致,也得到了多重敏感性分析的证实。然而,ALF队列中并不存在与人口密度相关的明显差异:在这项全国范围内的回顾性队列研究中,在人口密度较低的地区候诊与MELD评分较高的重症LT候选者死亡率较高有关,这强调了纯粹基于固定距离的分配系统的局限性。
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来源期刊
JAMA Network Open
JAMA Network Open Medicine-General Medicine
CiteScore
16.00
自引率
2.90%
发文量
2126
审稿时长
16 weeks
期刊介绍: JAMA Network Open, a member of the esteemed JAMA Network, stands as an international, peer-reviewed, open-access general medical journal.The publication is dedicated to disseminating research across various health disciplines and countries, encompassing clinical care, innovation in health care, health policy, and global health. JAMA Network Open caters to clinicians, investigators, and policymakers, providing a platform for valuable insights and advancements in the medical field. As part of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications, JAMA Network Open contributes to the collective knowledge and understanding within the medical community.
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