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Abbreviations
DRI

donor risk index

MELD

Model for End-Stage Liver Disease

In the current health care reality, the goal of health care reform is to provide high-quality and effective care that is accessible to everyone. The new US federal program also include plans for reducing overall spending on health care, limiting inefficiencies in care, improving patient outcomes, limiting administrative costs, and increasing the availability of and access to primary care physicians. However, conflicts may arise in attempts to achieve the goals of the new health care reform act when we are caring for patients with certain complex illnesses such as advanced liver disease. Strategies that improve survival and quality of life in patients with end-stage liver failure may require the involvement of specialists and therapies that are not readily amenable to cost reduction. A recent report created by the Physicians Foundation was presented to the President and Congress to define the impact of health care reform on physicians and their practices.[1] In this comprehensive report, there are concise, apolitical, and data-driven conclusions about the impact of health care reform on physicians, surgeons, and the health system in the United States. The report contains an in-depth evaluation of the deepening shortage of physicians and surgeons in our country and the subsequent impact on health care. It is clear from this report that specialization of physicians and surgeons has encouraged more consolidated group practice arrangements among specialty care providers. The resulting large, multispecialty groups encourage specialists to predominantly practice in large population centers. The trend in graduate medical training toward specialization has led to greater regional concentrations of physicians, and this is, of course, mostly an urban phenomenon; however, currently approximately 20% of the US population lives in rural areas and small towns. Because of the limited availability of specialty care, pressure is placed on patients in rural areas and smaller towns to travel to larger areas for specialized care. Socioeconomic pressures, including the expenses of travel, lead some patients to defer the receipt of these types of services.

Liver transplantation is the only lifesaving therapy for patients with end-stage liver disease that is consistently associated with improved survival.[2, 3] However, access to deceased donor liver transplantation in the United States remains highly variable across subgroups and geographic areas, despite federal regulations directing the transplant community to design policies to reduce racial, socioeconomic, and geographic disparities in transplant access. For example, patients living in rural areas are less likely to be listed for and to receive solid organ transplants in comparison with urban residents with similar severity of illness,[4, 5] and this is likely because of reduced access to tertiary referral. In “Local Access to Subspecialty Care Influences the Chance of Receiving a Liver Transplant,” Barritt et al.[6] advance our understanding of the mediators of access to liver transplantation by demonstrating a positive correlation between local access to subspecialty gastroenterology care and the likelihood of liver transplantation after a tertiary referral has been made. Specifically, linking physician density data from the Dartmouth Atlas to transplant center data from 1485 adults referred for liver transplant evaluation at University of North Carolina hospitals in 2002-2010, the investigators found that each unit increase in gastroenterologists per 100,000 population was associated with a 12% higher likelihood of liver transplantation after referral when they controlled for rural residence versus urban residence and a variety of other factors; however, there are no data regarding referral rates of patients with liver disease based on access to subspecialty care in this article. Fifty-three percent of the patients referred to their transplant center came from rural counties, which were defined as counties with fewer than 250 people per square mile. Furthermore, in their referral population, there was no discernible difference in access to primary care providers between those who underwent transplantation and those who were listed for transplantation but did not undergo transplantation.

Will improving the gastroenterology specialty workforce numbers and distribution substantially improve transplant access and health care quality for patients with end-stage liver disease across our county? Importantly, this study by Barritt et al.[6] involved patients referred to a single transplant center. The accessibility, efficacy, and costs of liver transplantation are intimately linked to interactions of recipient disease severity, allograft supply, and donor quality, all of which may vary with geography. The adoption of severity of illness–based liver allocation in 2002 via the Model for End-Stage Liver Disease (MELD) score to promote a more equitable distribution of donated livers according to medical necessity and the mandatory sharing of organs among donor service areas for patients with MELD scores > 15 has not resolved geographic disparities in the organ supply or, therefore, access to transplantation.[7] In regions with the most limited organ supply due in part to competition amongst centers and the numbers of patients listed, the average MELD score is >28 at the time of transplantation, whereas the average MELD score is only 20 in noncompetitive donor service areas. A higher MELD score at transplant is associated with longer lengths of transplant stay, and this includes more use of pharmaceuticals, laboratory tests, radiographs, and dialysis services and, subsequently, increased costs of care.[8] In regions with reduced supplies, patients need to wait with higher MELD scores for longer periods before transplantation, and this sharply increases the costs of pretransplant care as well. To address the ongoing liver allograft shortage, transplant centers are increasingly using organs from donors with characteristics that increase the risk of allograft failure. Synergistic impacts of lower liver allograft quality and high recipient illness severity on overall transplant costs have been demonstrated. For example, on the basis of a linkage of the Organ Procurement and Transplantation Network Registry and cost accounting data from the University Health Consortium, we found that although patients in the lowest MELD quartile had a modest rise in cost when donors with the highest donor risk index (DRI) were used, the total cost of transplant care as a function of DRI was more pronounced in the highest MELD quartile (>28) and rose nearly $35,000 across DRI levels.[9]

Reforming the care of patients with end-stage liver failure is clearly more complex than simply increasing access to primary care services. The work of Barritt et al.[6] suggests that for patients with liver failure residing in large rural catchment areas, access to gastroenterology specialty care—not primary care—is an important mediator of liver transplant access and patient survival once they are listed. We also believe that in addition to optimizing the available specialty work force supporting and providing transplant services, efforts to address geographic variations in the organ supply within revisions to organ allocation systems should be a leading priority in the transplant community. Optimized organ distribution may offer the opportunity to control costs while ensuring equitable access to the gift of life for patients, regardless of their place of residence or socioeconomic status.

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