Check Up: Centralizing special care limits access

Posted: March 31, 2014

Concentrating specialized health services, such as trauma care, at a limited number of hospitals has been shown to help control costs and improve the quality of care.

But a new study by University of Pennsylvania researchers looks at a downside to such centralization: It can reduce access to care.

The study found that veterans who lived more than 100 miles from a designated Veterans Affairs liver transplant center were less likely to be placed on the waiting list or get a liver, and more likely to die, than veterans who lived closer.

"Our findings show that distance places patients who live far away at a disadvantage that may put their lives at risk," said David Goldberg, a Penn liver transplant specialist and lead author of the study in last week's Journal of the American Medical Association.

The Department of Veterans Affairs has authorized only five VA hospitals to do liver transplants. These are in Pittsburgh; Richmond, Va.; Nashville; Houston; and Portland, Ore. (Two more are being added, in Wisconsin and Florida.)

Asked for comment on the study, the VA said the agency "provides world-class care before, during, and after the procedure for Veterans who receive transplants or any other surgery. A full team of medical and support personnel work together toward the best possible outcome for each Veteran we care for."

Goldberg, who did some of his training at the Philadelphia VA hospital, saw anecdotally that local veterans with failing livers faced hardships when their only hope for a transplant meant going to Pittsburgh.

The veteran has to travel to a transplant center to be evaluated for the waiting list. If he is sick enough to qualify for the list, he has to be able to get to the center within a set number of hours after an organ becomes available. And post-transplant, he, and a support person, must commit to live near the transplant center for a month for follow-up care.

To analyze the impact of geographic obstacles, the Penn researchers reviewed the Veterans Health Administration's electronic medical database for 50,600 liver-transplant-eligible veterans from 2003 through 2010.

Among veterans with severe liver disease, 7 percent who lived within 100 miles of a transplant center were wait-listed, compared with 3 percent who lived more than 100 miles away. The farther away they lived, the less likely they were to be listed.

Among those who made it onto the waiting list, 64 percent who lived within 100 miles got a liver, compared with 55 percent who lived farther away.

In addition, greater distance was linked to worse 5-year survival rates for wait-listed veterans.

The researchers suggested that the VA might be able to reduce these barriers by allowing patients' local physicians to do waiting-list evaluations and more post-transplant care.

They also see broader implications because "as complex, expensive medical technology evolves, certain services may only be offered at a limited number of sites." Proton beam therapy is an example.

"The issue of distance and access to care is critical given the focus on accountable care organizations that create large networks of physicians and hospitals," they concluded.



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