Geographic disparities in access to organ transplant in France

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Impact of County Health Rankings on Nationwide Liver Transplant Outcomes

BACKGROUND

There is limited information concerning whether social determinants of health affect postliver transplant (LT) outcomes. This study aims to understand to what extent the health of LT recipients' counties of residence influence long-term LT outcomes.

METHODS

We used the United Network for Organ Sharing data to identify adult LT recipients transplanted between January 2010 and June 2018. Patient-level data were matched to county-level County Health Ranking (CHR) data using transplant recipient zip code, and nationwide CHRs were created. Mixed-effects Cox proportional hazards models were used to examine associations between CHRs and graft and patient survival post-LT.

RESULTS

Health outcomes rank was significantly associated with posttransplant graft and patient survival, with worst tertile counties showing a 13% increased hazard of both graft failure and patient mortality compared to the best tertile counties.

CONCLUSIONS

Although county health is associated with LT outcomes, it also appears that LT recipient selection is effective at mitigating major disparities based on county of residence and helps yield equitable outcomes in this respect.

Between-center disparities in access to heart transplantation in France: contribution of candidate and center factors - A comprehensive cohort study

Transplantation represents the last option for patients with advanced heart failure. We assessed between-center disparities in access to heart transplantation in France 1 year after registration and evaluated the contribution of factors to these disparities. Adults (n = 2347) registered on the French national waiting list between January 1, 2010, and December 31, 2014, in the 23 transplant centers were included. Associations between candidate and transplant center characteristics and access to transplantation were assessed by proportional hazards frailty models. Candidate blood groups O and A, sensitization, and body mass index ≥30 kg/m² were independently associated with lower access to transplantation, while female gender, severity of heart failure, and high serum bilirubin levels were independently associated with greater access to transplantation. Center factors significantly associated with access to transplantation were heart donation rate in the donation service area, proportion of high-urgency candidates among listed patients, and donor heart offer decline rate. Between-center variability in access to transplantation increased by 5% after adjustment for candidate factors and decreased by 57% after adjustment for center factors. After adjustment for candidate and center factors, five centers were still outside of normal variability. These findings will be taken into account in the future French heart allocation system.

Impact of geography on organ allocation: Beyond the distance to the transplantation center

AIM

To illustrate the application and utility of Geographic Information System (GIS) in exploring patterns of liver transplantation. Specifically, we aim to describe the geographic distribution of transplant registrations and identify disparities in access to liver transplantation across United Network of Organ Sharing (UNOS) region 1.

METHODS

Based on UNOS data, the number of listed transplant candidates by ZIP code from 2003 to 2012 for Region 1 was obtained. Choropleth (color-coded) maps were used to visualize the geographic distribution of transplant registrations across the region. Spatial interaction analysis was used to analyze the geographic pattern of total transplant registrations by ZIP code. Factors tested included ZIP code log population and log distance from each ZIP code to the nearest transplant center; ZIP code population density; distance from the nearest city over 50000; and dummy variables for state residence and location in the southern portion of the region.

RESULTS

Visualization of transplant registrations revealed geographic disparities in organ allocation across Region 1. The total number of registrations was highest in the southern portion of the region. Spatial interaction analysis, after adjusting for the size of the underlying population, revealed statistically significant clustering of high and low rates in several geographic areas could not be predicted based solely on distance to the transplant center or density of population.

CONCLUSION

GIS represents a new method to evaluate the access to liver transplantation within one region and can be used to identify the presence of disparities and reasons for their existence in order to alleviate them.

Are there geographical disparities in access to liver transplantation in Atlantic Canada?

OBJECTIVE

To characterize the patient population served by Atlantic Canada's Multi-Organ Transplant Program liver transplant service over the first five years of activity in its current iteration.

METHODS

Data from a prospective institutional database, supplemented by retrospective medical record review, were used to identify and characterize the cohort of patients assessed for consideration of first liver transplant between December 1, 2004 and December 1, 2009.

RESULTS

In the five-year period after reactivation, the program assessed 337 patients for first liver transplant. The median age at referral for this group of 199 men (59.0%) and 138 women (41.0%) was 56.1 years (range 16.3 to 72.3 years). The leading three liver diseases indicating liver replacement were alcohol-related end-stage liver disease (20.5%), hepatocellular cancer (16.6%) and hepatitis C-related end-stage liver disease (14.0%). When evaluated according to provincial population-standardized incidence, significant differences in the incidence of liver transplant assessment among the four Atlantic Canadian provinces were found (per 100,000 inhabitants: Nova Scotia 19.8, New Brunswick 13.0, Newfoundland and Labrador 9.1 and Prince Edward Island 11.0; Fisher's exact P<0.001). Of the 337 individuals who began the assessment process, 153 (45.4%) were assigned to the wait list. The probability of an individual being assigned to the wait list was not found to differ according to province of residence (Nova Scotia 45.3%, New Brunswick 40.0%, Newfoundland and Labrador 58.7% and Prince Edward Island 40.0%; Fisher's exact P=0.206).

CONCLUSIONS

The analysis suggests that there are geographical disparities in access to liver transplantation in Atlantic Canada. These disparities appear to be related to factors that precede the transplant assessment process.

[Organ transplantation in Brazilian States: effectiveness, productivity, and capacity]

This study focused on key aspects of organ transplantation programs in various States of Brazil. The study showed wide disparities between States, based on various performance indicators. States in the South, Southeast, and Midwest regions had the highest transplantation and productivity rates and the largest per capita transplantation teams. São Paulo proved to be a benchmark due to its high performance on several indicators.

Geographic variation in end-stage renal disease incidence and access to deceased donor kidney transplantation

The effect of demand for kidney transplantation, measured by end-stage renal disease (ESRD) incidence, on access to transplantation is unknown. Using data from the U.S. Census Bureau, Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR) from 2000 to 2008, we performed donation service area (DSA) and patient-level regression analyses to assess the effect of ESRD incidence on access to the kidney waiting list and deceased donor kidney transplantation. In DSAs, ESRD incidence increased with greater density of high ESRD incidence racial groups (African Americans and Native Americans). Wait-list and transplant rates were relatively lower in high ESRD incidence DSAs, but wait-list rates were not drastically affected by ESRD incidence at the patient level. Compared to low ESRD areas, high ESRD areas were associated with lower adjusted transplant rates among all ESRD patients (RR 0.68, 95% CI 0.66-0.70). Patients living in medium and high ESRD areas had lower transplant rates from the waiting list compared to those in low ESRD areas (medium: RR 0.68, 95% CI 0.66-0.69; high: RR 0.63, 95% CI 0.61-0.65). Geographic variation in access to kidney transplant is in part mediated by local ESRD incidence, which has implications for allocation policy development.

Disparidades nas filas para transplantes de órgãos nos estados brasileiros

Avaliamos alguns aspectos dos transplantes de órgãos nas Unidades da Federação brasileira, nos anos de 2004, 2005 e 2006. Estimamos, com base em um modelo de teoria das filas, os tempos de espera para transplantes de coração, córnea, fígado, pulmão, rim, pâncreas, e transplante simultâneo de rim e pâncreas. Os resultados indicam redução na espera por alguns órgãos (córnea, e pâncreas); elevação em outros (fígado, coração, rim/pâncreas); e ligeiras flutuações, sem tendência muito definida, nos transplantes de rim e nos transplantes de pulmão ao longo do período estudado. Os estados das regiões Sul e Sudeste (com a exceção do Rio de Janeiro) e Centro-oeste têm os menores tempos de espera e as maiores taxas de atendimento do país.

International Study of Health Care Organization and Financing for end-stage renal disease in France

The major features of ESRD management in France include the predominance of hemodialysis and the resulting competition for dialysis stations. In 2003, the prevalence of ESRD in France was 0.087%. Of the 52,000 ESRD patients, 30,882 were receiving dialysis and 21,233 had functioning renal transplants. The annual expenditure per ESRD patient in 2003 was estimated at euro40,975. Autodialysis, at euro49,133 per patient per year, was much less expensive than dialyzing in-center at either a public or private facility (euro111,006 and euro75,125, respectively). Transplant activity in France has rapidly increased in recent years, reaching 22 donors per million population in 2005.

Residence location and likelihood of kidney transplantation

BACKGROUND

In a universal, public health care system, access to kidney transplantation should not be influenced by residence location. We determined the likelihood of kidney transplantation from deceased donors among Canadian dialysis patients living in 7 geographic regions. Within each region we also determined whether distance from the closest transplant centre was associated with the likelihood of transplantation.

METHODS

A random sample of 7034 subjects initiating dialysis in Canada between 1996 and 2000 was studied. We used Cox proportional hazards models to examine the relation between residence location and the likelihood of kidney transplantation from deceased donors over a median period of 2.4 years.

RESULTS

There were significant differences in the likelihood of kidney transplantation from deceased donors and predicted waiting times between the different geographic regions. For example, the adjusted relative likelihood of transplantation in Alberta was 3.74 (95% confidence interval [CI] 2.95-4.76) compared with the likelihood in Ontario (p < 0.001). These differences persisted after further adjustment for differences in the rate of deceased organ donation. Within regions, patients who resided 50.1-150 km, 150.1-300 km and more than 300 km from the closest transplant centre had a similar adjusted likelihood of receiving a kidney transplant as those who lived less than 50 km away.

INTERPRETATION

The adjusted likelihood of undergoing a kidney transplant from a deceased donor varied substantially between geographic regions in Canada. In contrast, the likelihood of transplantation within regions was not affected by distance from the closest transplant centre.

Air transportation of patients with end-stage liver disease to distant liver transplantation centers

The Israeli population does not meet its transplantation organ needs. Therefore, liver transplantation (LTX) candidates are sometimes transported to centers abroad. We aimed to assess the demographic and clinical issues concerning this policy. Records of all candidates transported (2000-2004) were retrospectively reviewed. Data included etiology, disease severity, outcome, distances traveled and destinations, and medical complication arising en route. Forty-three candidates were transported overseas: 12 patients with fulminant hepatic failure (FHF) and 31 with cirrhosis. Average MELD score was 19.94, and the APACHE II score for patients with FHF was 20.5. Destinations included the United States, Colombia, Belgium, Germany, China, and Italy. Average distance traveled was 4,660 miles. Two patients were intubated and sedated during flight. All patients safely reached their destinations: 8 died prior to transplantation, 5 died after transplantation, 3 are awaiting transplantation, 3 recovered spontaneously, and the rest successfully underwent transplantation and returned home. In conclusion, our results suggest that long-distance transportation of patients awaiting liver transplantation is safe and technically feasible provided precaution measures are taken. Therefore, allocation regions may be broadened to include larger and more distant populations.

Ability to pay and geographical proximity influence access to liver transplantation even in a system with universal access

Ireland, in common with many countries, has a mixed private and public health care system. Concern has been expressed that this system may lead to inequity in access to medical treatment. To investigate this concern, all contacts and first admissions to the national liver transplant unit were identified between April 1, 2000, and March 31, 2002. The effects of private health insurance and area of residence on the likelihood of receiving a liver transplant were assessed. A total of 202 patients were admitted. Forty-three patients from this cohort received a liver transplant (21.3%). Of patients with private health insurance, 17 of 50 (34.0%) were transplanted, compared with 26 of 152 (17.1%) without private health insurance (relative risk [RR] = 1.99; 95% CI, 1.18-3.35; P = .01). For residents of the Eastern (close to the liver transplant unit), patients with private health insurance were no more likely to be transplanted (RR = 0.95; 95% CI, 0.35-2.54; P = 1.0), whereas for residents of other areas, patients with private insurance were 3 times more likely to receive a transplant than those without health insurance (RR = 3.11; 95% CI, 1.59-6.08; P = .001). Patients living outside the Eastern region without private health insurance were only half as likely as all other patient types combined to receive a transplant (RR = 0.52; 95% CI, 0.29-0.92; P = .02). In this study the possession of private health insurance appeared to increase the chances of receiving a liver transplant. Patients without private health insurance living distant from the liver transplant unit appeared particularly disadvantaged. In conclusion, these findings suggest significant inequity in liver transplant allocation in Ireland and deserve further assessment.

Geographic disparities in access to organ transplantation in the United Kingdom

In the United Kingdom, geographic variations in access to transplantation seem to exist-median waiting time to transplantation ranges between 305 and 1,236 days for kidney recipients, 36 and 73 days for liver recipients, and 66 and 667 days for heart recipients (although this latter example must be interpreted with caution). These variations may result from a number of factors. Different patterns of end-stage organ disease are particularly relevant for patients with kidney failure. Protocols for transplant assessment are now available and may reduce inequality. Regional variations in donation rates also exist but are poorly understood.

Geographic variance in access to renal transplantation in Australia

BACKGROUND

Geographic disparities in access to transplantation in Australia during the past 15 years have been accentuated by the increasing size of the transplant waiting lists in each state and by low cadaveric donation rates. Access to dialysis treatment is similar in all states of Australia, although there are fewer elderly dialysis patients in South Australia.

RESULTS

Access to the transplant waiting list varies significantly between the states, with one state having 39 per million population (pmp) on their list compared with the two most populous states at 113 pmp and 101 pmp. Patients between the ages of 25 and 54 years in one state had twice the chance of being on the waiting list compared with another. Transplantation rates reflect both the cadaveric donor rate (16.9 transplants pmp) and the large contribution from living donors (39% of all transplants in 2001). Transplantation with a kidney in Australia is dependent both upon age and the state of residence, with one state performing transplantations with 15% of their dialysis population each year but all other states achieving less than 10%, with an average of 8% for the country as a whole.

CONCLUSIONS

Criteria for access to the transplantation waiting list in each state vary, depending perhaps upon whether a general community or individual patient perspective is the dominant policy. Access to transplantation on the other hand is reflective of each states' cadaveric donation rate modified by increasing use of living donors, especially in younger patients.