County Level Differences in Liver-Related Mortality, Waitlisting, and Liver Transplantation in the United States

• Authors: Robert M. Cannon, University of Alabama at Birmingham; Ariann Nassel, University of Alabama at Brimingham; Jeffery T. Walker, University of Alabama at Birmingham; Saulat S. Sheikh, University of Alabama at Brimingham; Babak J. Orandi, University of Alabama at Birmingham; Malay B. Shah, University of Kentucky; Raymond Lynch, Emory University; David S. Goldberg, University of Miami; Jayme E. Locke, University of Alabama at Birmingham
• Journal Title: Transplantation
• Volume: Volume 106, Number 9
• Publisher: Wolters Kluwer Health, Inc. | 2022-05-09, Pages 1799-1806
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1097/TP.0000000000004171
• Subjects: Health Sciences, Epidemiology
• Keywords: transplantation; lung transplantation; waitlist time

Abstract

Background: Much of our understanding regarding geographic issues in transplantation is based upon statistical techniques that do not formally account for geography, and is based upon obsolete boundaries such as donation service area. Methods: We applied spatial epidemiologic techniques to examine liver-related mortality and access to liver transplant services at the county level using data from the CDC and SRTR from 2010 through 2018. Results: There was significant negative spatial correlation between transplant rates and liver-related mortality at the county level (Moran’s I −0.319; p=0.001). Significant clusters were identified with high transplant rates and low liver-related mortality. Counties in geographic clusters with high ratios of liver transplants to liver related deaths had more liver transplant centers within 150 nautical miles (6.7 centers vs. 3.6 centers; p<0.001) compared to all other counties, as did counties in geographic clusters with high ratios of waitlist additions to liver-related deaths (8.5 centers vs. 2.5 centers; p<0.001). The spatial correlation between waitlist mortality and overall liver-related mortality was positive (Moran’s I 0.060; p=0.001) but weaker. Several areas with high waitlist mortality had some of the lowest overall liver-related mortality in the country. Conclusions: These data suggest that high waitlist mortality and allocation MELD don’t necessarily correlate with decreased access to transplant, while local transplant center density is associated with better access to waitlisting and transplant