The findings illustrate some of the potential
unintended consequences of centralizing medical resources for
specialized care, according to the study's authors.
"When designing these systems, it's important to keep this geography
issue (as) an important feature," Dr. David Goldberg told Reuters
Health. "Otherwise, it could get lost."
Goldberg is the study's lead author from the Hospital of the
University of Pennsylvania in Philadelphia.
He and his colleagues note in the Journal of the American Medical
Association that centralizing healthcare is a way to control costs,
concentrate expertise and limit differences in the quality of care
While those approaches may be efficient, any benefit could be offset
by patients having to travel long distances to access the care, they
To see whether distance to centralized care is connected to outcomes
for patients, the researchers analyzed data on liver patients within
the Department of Veterans Affairs (VA).
The VA has five liver transplant centers nationwide, but veterans
with additional insurance, such as Medicare, can use other
The researchers analyzed VA liver transplant records from 2003 to
2010. Overall, they had data on 50,637 veterans who were potentially
eligible for transplants. Some 6 percent were put on waiting lists
for a new liver — about half of those at VA transplant centers.
Of the patients receiving care at VA hospitals within 100 miles of a
VA transplant center, about 7 percent were waitlisted at the VA
centers and about 10 percent were waitlisted at any center.
That compared to about 3 percent having been waitlisted at VA
centers and about 5 percent waitlisted at any center when veterans
were being treated more than 100 miles from the closest VA
Once on a waiting list, those veterans who were living farther away
from a transplant center were less likely to get transplants, too.
And the likelihood of a liver patient dying over a five-year period
rose with distance.
[to top of second column]
For example, a veteran living within 25 miles of a VA transplant
center had about a 63 percent chance of being alive five years
later, compared to about a 60 percent chance among people living
more than 100 miles from a VA transplant center.
Organ transplant programs are highly specialized and organically
require centralization, the authors acknowledge. Doctors would want
patients available after a liver transplant for close monitoring and
visits up to several times a week, Goldberg said.
It's possible that people living farther away from the VA
transplant centers are less likely to even be evaluated for
transplants because of the long distance, the researchers suggest.
Alternatively, it could be that the transplant cannot move forward
because patients and their families can't or won't relocate closer
to the centers.
"While this issue of centralizing care may have many potential
positives by concentrating expertise in one area, there are these
unintended consequences that need to be considered," Goldberg said.
The study is not intended to be an indictment of the VA's transplant
system, he added. In fact, the VA has approved the creation of two
new transplant centers.
"I think that is one thing the VA should be credited for," Goldberg
JAMA, online March 25, 2014.
[© 2014 Thomson Reuters. All rights
Copyright 2014 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.