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Rates of Solid-Organ Wait-listing, Transplantation, and Survival Among Residents of Rural and Urban Areas
David A. Axelrod, MD, MBA;
Mary K. Guidinger, MS;
Samuel Finlayson, MD;
Douglas E. Schaubel, PhD;
David C. Goodman, MD;
Michael Chobanian, MD;
Robert M. Merion, MD
JAMA. 2008;299(2):202-207.
Context Disparities in access to organ transplantation exist for racial minorities, women, and patients with lower socioeconomic status or inadequate insurance. Rural residents represent another group that may have impaired access to transplant services.
Objective To assess the association of rural residence with waiting list registration for heart, liver, and kidney transplant and rates of transplantation among wait-listed candidates.
Design, Setting, and Patients Five-year US cohort of 174 630 patients who were wait-listed and who underwent heart, liver, or kidney transplantation between 1999 and 2004.
Main Outcome Measures Rates of new waiting list registrations and transplants per million population for residents of 3 residential classifications (rural/small town population, <10 000; micropolitan, 10 000-50 000; and metropolitan >50 000 or suburb of major city).
Results Compared with urban residents, waiting list registration rates for rural/small town residents were significantly lower for heart (covariate-adjusted rate ratio [RR] = 0.91; 95% confidence interval [CI], 0.86-0.96; P<.002), liver (RR = 0.86; 95% CI, 0.83-0.89; P<.001), and kidney transplants (RR = 0.92; 95% CI, 0.90-0.95; P<.001). Compared with residents in urban areas, rural/small town residents had lower relative transplant rates for heart (RR = 0.88; 95% CI, 0.81-0.94; P = .004), liver (RR = 0.80; 95% CI, 0.77-0.84; P<.001), and kidney transplantation (covariate-adjusted RR = 0.90; 95% CI, 0.88-0.93; P<.001). These disparities were consistent across national organ allocation regions. Significantly longer waiting times among rural patients wait-listed for heart transplantation were observed but not for liver and kidney transplantation. There were no significant differences in posttransplantation outcomes between groups.
Conclusions Patients living in rural areas had a lower rate of wait-lisiting and transplant of solid organs, but did not experience significantly different outcomes following transplant. Differences in rates of wait-listing and transplant may be due to variations in the burden of disease between different patient groups or barriers to evaluation and waiting list entry for rural residents with organ failure.
Author Affiliations: Department of Surgery, Dartmouth Medical School, Lebanon, New Hampshire (Drs Axelrod, Finlayson, and Chobanian); Scientific Registry of Transplant Recipients, Arbor Research Collaborative for Health, Ann Arbor, Michigan (Ms Guidinger and Dr Merion); Department of Pediatrics, Dartmouth Medical School (Dr Goodman); Department of Biostatistics, University of Michigan, Ann Arbor (Dr Schaubel); Division of Transplantation, Department of Surgery, University of Michigan, Ann Arbor (Dr Merion); and The Dartmouth Institute for Health Policy and Clinical Practice (Dr Goodman).
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