Where You Live Matters for Lifesaving Liver Transplants

Published on June 15, 2014

Broad-shouldered, deeply tanned and in his 50s, the farmer had ignored his worsening fatigue until the morning he realized that the whites of his eyes had turned yellow. His liver was failing, and when a specialist a few towns over informed him that he might not survive the year, he asked for the closest transplant center.

The closest transplant center was ours, and it was more than 100 miles away.

Undaunted, he and his wife drove to and from our hospital every day for more than a week for the testing and consultations necessary to determine if he could tolerate the radical operation and manage the complex postoperative care of a transplant. Depending on the traffic, the journey could take half a day, so the patient and his wife quickly figured out the best hours and routes to minimize their travel time.

“Forget about the new liver,” he joked after finally being placed on the transplant waiting list. “I’m ready for a new car!”

Almost a year later, a liver became available for the man. But because the liver was already “on ice,” there were only a few hours before it would deteriorate to the point at which it would no longer work. Our transplant coordinators immediately began making preparations to bring the patient in, assemble the surgical team and start the operation that would remove his old, diseased liver to make room for the new.

But the man never got the transplant. Living as far away as they did, he and his wife couldn’t get to our hospital fast enough.

A few months later, he died from liver failure.

He, and the other patients I have known like him, came to mind when I read a recent study in JAMA on how policies restricting care to specialized regional centers can affect patient outcomes.

The researchers combed through the records of the over 50,000 veterans administration patients who were classified as eligible for a liver transplant from 2003 to 2010 and found that almost 1,500 had been placed on the waiting list for transplant at one of the five transplant centers. But the farther those patients lived from a V.A. transplant center, the less likely they were to be on the waiting list. And if they did manage to get on the list, they were less likely to receive a transplant compared with patients who lived closer.

Following the age-old adage that practice makes perfect, such policies limit where patients can undergo certain complex treatments or procedures to the centers that have the expertise to do them most efficiently. Patients end up being channeled to those centers, which in turn helps the clinicians there become even more adept and swift, thus ensuring quality of care and, potentially, significant cost savings as well.

It appears to be a winning situation for both doctors and patients.

Not surprisingly, insurers and third party payers, with the support of health care policy experts, have embraced centralized care, covering certain procedures only if they are performed at selected high-volume institutions. Research linking improved patient outcomes to greater clinician experience has helped to support these regulations, with some studies even quantifying the threshold number of procedures after which an institution might have better mortality rates.

Even if patients have to travel far from home, experts and insurers believe that the improvement in quality and decrease in cost more than makes up for the separation from friends and family.

There have been critics, however. They contend that patients who live far away from these so-called centers of excellence might not be as likely to get the care they need and, as a result, could fare worse than patients who live close by.

But few insurers or payers have paid heed to these assertions. While there is an ever-growing body of research that supports regionalizing care, only a few studies have shown that geographic concentration of expertise leads to disparities. For the critics to prove their point, they would need to show the impact of limiting a potentially life-or-death treatment to a handful of centers in the context of a large, even national, health care system. And such a system did not seem to exist.

Now a group of researchers from Philadelphia appears to have found one. And their analysis of patient outcomes not only confirms what critics have long feared but also reveals how even the most self-evident policy choices can have unforeseen and potentially devastating consequences.

Furthermore, the farther they lived from the center, the more likely they were to die waiting for a transplant.

“Centralizing care concentrated expertise, but it also isolated certain populations,” said Dr. David Seth Goldberg, lead author and an instructor in medicine at the Perelman School of Medicine at the University of Pennsylvania. “In this case, the Midwest became a black hole.”

Although the study uncovered an unintended consequence of consolidating liver transplant care for veterans, the findings have important implications outside the V.A. system. Such consolidation of complex procedures is occurring in other health care systems, too, and maps that display the geographic distribution of treatment centers are eerily similar to the map of V.A. liver transplant centers.

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While Dr. Goldberg and his co-authors acknowledge that costly treatments cannot be offered everywhere, they do believe that health care systems should begin to consider not only population density but also potential geographic barriers when regionalizing care.

“If the goal is to make treatment available to all sectors of the population,” Dr. Goldberg said, “we need to look at maps when developing these sites and not just population density. Geography matters.”

 

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