Geographical Distance from Transplant Center and Impact on Waitlist Outcomes and Healthcare Utilization Pre-Listing.

Abstract

BACKGROUND AIMS Decompensated cirrhosis has a median survival of two years without liver transplantation (LT). This study investigates if distance from LT center affects waitlist mortality and receipt of LT. METHODS The study population was generated from the transplant database in London, Ontario, Canada. Adult patients on the waitlist for LT between January 1, 2012 and December 31, 2021, were included. Data was linked to the Institute for Clinical Evaluative Sciences (ICES) to examine clinically relevant outcomes, using ≤150km vs >150km to stratify descriptive analysis. Multivariate time-to-event analyses were conducted to evaluate the hazards of increasing distance from LT center on waitlist mortality and receipt of LT. RESULTS Of the 552 patients meeting study criteria, 394 (71.4%) received LT in an overall predominantly male cohort (n=390, 70%), with a median age of 59 years (IQR 52-64) and median distance from the LT center of 110 km (IQR 59-191). There were no significant differences between patients living ≤150 km (n=362) vs >150 km (n=190) from the LT center. In terms of liver disease etiology-alcohol-related liver disease remained the most common (32.9% vs 33.2%; p=0.95) across both categories, with no difference in median MELD-Na scores between those that did and did not receive transplant(17 [IQR 9-25] vs 18 [IQR 10-27]; p=0.12). On multivariable analysis, distance to the LT center did not impact receipt of LT, waitlist mortality, or post-listing ED visits and hospitalizations. MELD-Na at listing was a significant predictor of increased waitlist mortality (HR 1.12; CI 1.09-1.16; p<0.01), while hepatocellular carcinoma (HCC) diagnosis was associated with reduced waitlist mortality (HR 0.13; CI 0.04-0.45; p <0.01). Patients further from the LT center had a higher median number of hospitalizations (2 vs 1; p=0.02) and emergency room (ED) visits (3 vs 2; p <0.01) in the year before LT listing, and significantly ED utilization within 90 days post-listing (0 [IQR 0-2] vs 0 [IQR 0-1]; p<0.05), albeit this was not consistent on multivariable analysis. CONCLUSION Geographical distance does not significantly impact LT waitlist mortality or receipt of LT. However, differences in healthcare utilization suggest disparities may still manifest with a negative impact on patients in the pre-LT setting.