Axelrod David A, Guidinger Mary K, Finlayson Samuel, Schaubel Douglas E, Goodman David C, Chobanian Michael, Merion Robert M
Department of Surgery, Dartmouth Medical School, Lebanon, New Hampshire, USA.
JAMA. 2008 Jan 9;299(2):202-7. doi: 10.1001/jama.2007.50.
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.
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.
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).
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.
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.
少数族裔、女性以及社会经济地位较低或保险不足的患者在器官移植可及性方面存在差异。农村居民是另一类可能在获取移植服务方面受限的群体。
评估农村居住情况与心脏、肝脏和肾脏移植等待名单登记以及等待名单上候选者的移植率之间的关联。
设计、设置和患者：对1999年至2004年间在美国等待名单上并接受心脏、肝脏或肾脏移植的174,630名患者进行了为期五年的队列研究。
3种居住分类（农村/小镇人口，<10,000；微都市，10,000 - 50,000；大都市>50,000或大城市郊区）居民每百万人口的新等待名单登记率和移植率。
与城市居民相比，农村/小镇居民的心脏移植等待名单登记率显著较低（协变量调整率比[RR]=0.91；95%置信区间[CI]，0.86 - 0.96；P<.002）、肝脏移植（RR = 0.86；95% CI，0.83 - 0.89；P<.001）和肾脏移植（RR = 0.92；95% CI，0.90 - 0.95；P<.001）。与城市地区居民相比，农村/小镇居民的心脏相对移植率较低（RR = 0.88；95% CI，0.81 - 0.94；P =.004）、肝脏移植（RR = 0.80；95% CI，0.77 - 0.84；P<.001）和肾脏移植（协变量调整RR = 0.90；95% CI，0.88 - 0.93；P<.001）。这些差异在全国器官分配区域中是一致的。观察到农村等待心脏移植的患者等待时间明显更长，但肝脏和肾脏移植患者并非如此。两组之间移植后结局无显著差异。
农村地区患者的实体器官等待名单登记率和移植率较低，但移植后结局无显著差异。等待名单登记率和移植率的差异可能是由于不同患者群体之间疾病负担的差异或农村器官衰竭居民在评估和进入等待名单方面的障碍。
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