Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA.
Transplantation. 2013 Jan 27;95(2):361-71. doi: 10.1097/TP.0b013e3182737cfb.
Disparity in access to liver transplantation (LT) in the United States persists despite directives from the federal government to reduce geographic variation. We assessed the impact of socioeconomic status (SES) and traveling to alternative donation service areas (DSAs) on patient survival.
A prospective cohort study integrating transplant registry and U.S. Census data was analyzed using multivariate linear Cox proportional hazards models. A separate matched-pairs analysis was used to assess the benefit of traveling on patient survival and transplantation rate.
High SES is associated with increased access to LT (adjusted hazard ratio [aHR], 1.05; 95% confidence interval [95% CI], 1.01-1.08) and reduced mortality after waitlisting (aHR [95% CI], 0.88 [0.85-0.93]). Increased access is mediated, in part, through inter-DSA travel. Travel was associated with high SES, white race, blood group O, private insurance, and residence in regions 1, 5, and 11. Transplant candidates in the highest SES quartile were approximately 70% more likely to travel (aHR [95% CI], 1.67 [1.43-1.97]) than those in the lowest SES quartile. Compared with matched control patients, travelers were 74% more likely to be transplanted (aHR [95% CI], 1.74 [1.56-1.94]) and 20% less likely to die after listing (aHR [95% CI], 0.79 [0.69-0.92]).
High SES and inter-DSA travel are strongly associated with increased LT access and reduced mortality. Travelers are more likely to be sociodemographically advantaged and privately insured and to live in regions with reduced access to deceased-donor organs.
尽管联邦政府发布指令要求减少地域差异，但美国在肝移植（LT）方面的可及性仍存在差异。我们评估了社会经济地位（SES）和前往替代供体服务区（DSA）对患者生存的影响。
通过多变量线性 Cox 比例风险模型分析了整合移植登记处和美国人口普查数据的前瞻性队列研究。使用配对分析来评估旅行对患者生存和移植率的获益。
高 SES 与 LT 可及性增加相关（校正后的危险比[aHR]，1.05；95%置信区间[95%CI]，1.01-1.08），并降低了等待名单后的死亡率（aHR[95%CI]，0.88 [0.85-0.93]）。这种增加在一定程度上是通过跨 DSA 旅行来实现的。旅行与高 SES、白种人、血型 O、私人保险以及居住在第 1、5 和 11 区有关。SES 最高四分位数的移植候选人旅行的可能性大约高 70%（aHR [95%CI]，1.67 [1.43-1.97]），而 SES 最低四分位数的患者旅行的可能性低 70%。与匹配的对照患者相比，旅行者的移植率高 74%（aHR [95%CI]，1.74 [1.56-1.94]），而名单后的死亡率低 20%（aHR [95%CI]，0.79 [0.69-0.92]）。
高 SES 和跨 DSA 旅行与 LT 可及性增加和死亡率降低密切相关。旅行者更有可能在社会人口统计学上处于优势地位，有私人保险，并居住在获得死者供体器官机会减少的地区。
