Listing at non-local transplant centers is associated with increased access to deceased donor kidney transplantation

Abstract

The ability of kidney transplant candidates to travel outside of their usual place of care varies by sociodemographic factors, potentially exacerbating disparities in access. We used Transplant Referral Regions (TRRs) to overcome previous methodological barriers of using geographic distance to assess the characteristics and outcomes of patients listed for kidney transplant at centers in neighboring TRR or beyond neighboring TRRs. Among listed kidney transplant candidates, 20.9% traveled to a neighbor and 5.6% beyond a neighbor. A higher proportion of travelers were White, had some college education, and lived in ZIP codes with lower poverty. Travel to a neighbor was associated with a 7% increase in likelihood of deceased donor transplant (cHR: 1.07, 95% CI: 1.05, 1.09) and traveling beyond a neighbor with a 19% increase (cHR: 1.19, 95% CI: 1.15, 1.24). Travelers had similar rates of living donor transplant and waitlist mortality as patients who did not travel; those who traveled beyond a neighbor had slightly lower posttransplant mortality (HR: 0.91, 95% CI: 0.83, 0.99). In conclusion, the ability to travel outside of the recipient's assigned TRR increases access to transplantation and improves long‐term survival.

Non-local kidney transplantation and transplant outcomes

“…To the Editor, Ross-Driscoll et al recently investigated the impact of healthcare at a non-local transplant center and kidney transplant outcomes. 1 We would like to highlight several points regarding their pioneering and insightful work. First, paramount to the study is a novel, authorscreated concept of transplant referral region (TRR) that incorporates the geographic catchment areas of a transplant center.…”

“…First, paramount to the study is a novel, authorscreated concept of transplant referral region (TRR) that incorporates the geographic catchment areas of a transplant center. 1,2 A local "home" TRR was assigned to the transplant center that historically cared for the greatest number of patients of a specific zip code.…”

“…Second, the authors expressed deceased and living donor transplant rates and pretransplant mortality per 100 person-years (PY) of each study category (Table 2, Ref. [1]). Importantly, the authors' calculation of total PY included the person-time of candidates who were still waitlisted at study end.…”

“…The lesser "dilution" in the latter two "travel" categories could, at least in part, account for the observed increase in event hazard ratios in these categories (Tables 2 and 3, Ref. [1]) The authors, therefore, should substantiate the seeming increased access to transplantation by comparing the "time to transplant" of the three "travel" groups.…”

Response to “non-local kidney transplantation and transplant outcomes”

“…in our sensitivity analysis, without this clustering, our ability to accurately identify catchment regions was curtailed by the inherent heterogeneity in center selection in an area served by more than one center. 3 While we do acknowledge that the 10-mile criterion is somewhat arbitrary, this is a limitation inherent to dichotomizing a continuous variable. We believe that our sensitivity analysis demonstrates that the 10-mile criterion does a reasonable job of describing care patterns in the United States, performing similarly to a 15-mile criterion and better than a 5-mile criterion.…”