Association between Longer Travel Distance for Transplant Care and Access to Kidney Transplantation and Graft Survival in the United States
Adrian M. Whelan, Kirsten L. Johansen, Sandeep Brar, Charles E. McCulloch, Deborah Adey, Garrett R. Roll, Barbara Grimes, Elaine Ku
Abstract
Significance Statement Kidney transplantation rates and outcomes vary across transplant centers. Some patients may gain an advantage by traveling to a center with characteristics more favorable than those of the center nearest their residence. The authors examined patient and center characteristics associated with longer travel distance and the latter’s association with receipt of kidney transplantation and graft survival in the United States. Patients were more likely to travel farther if they were of non-Black race or if the nearest center had a lower volume of living donor surgeries. Longer travel distance associated with higher likelihood of living donor transplantation but lower likelihood of deceased donor transplantation, and it was weakly associated with higher graft failure risk. These findings provide insights into advantages (or lack thereof) of traveling beyond the nearest center for transplant care. Background Transplant candidates may gain an advantage by traveling to receive care at a transplant center that may have more favorable characteristics than their local center. Factors associated with longer travel distance for transplant care and whether the excess travel distance (ETD) is associated with access to transplantation or with graft failure are unknown. Methods This study of adults in the United States wait-listed for kidney transplantation in 1995–2015 used ETD, defined as distance a patient traveled beyond the nearest transplant center for initial waiting list registration. We used linear regression to examine patient and center characteristics associated with ETD and Fine–Gray models to examine the association between ETD (modeled as a spline) and time to deceased or living donor transplantation or graft failure. Results Of 373,365 patients, 11% had an ETD≥50 miles. Traveling excess distance was more likely among patients who were of non-Black race or those whose nearest transplant center had lower annual living donor transplant volume. At an ETD of 50 miles, we observed a lower likelihood of deceased donor transplantation (subhazard ratio [SHR], 0.85; 95% confidence interval [95% CI], 0.84 to 0.87) but higher likelihood of living donor transplantation (SHR, 1.14; 95% CI, 1.12 to 1.16) compared with those who received care at their nearest center. ETD was weakly associated with higher risk of graft failure. Conclusions Patients who travel excess distances for transplant care have better access to living donor but not deceased donor transplantation and slightly higher risk of graft failure. Traveling excess distances is not clearly associated with better outcomes, especially if living donors are unavailable.