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October 19, 2009

Quantifying Access to Surgical Care

Arch Surg. 2009;144(10):893. doi:10.1001/archsurg.2009.173


Access to Kidney Transplantation Among Remote- and Rural-Dwelling Patients With Kidney Failure in the United States

Marcello Tonelli, MD, SM; Scott Klarenbach, MD, MS; Caren Rose, MSc; Natasha Wiebe, MMath; John Gill, MD, MS

Context:  US residents with end-stage renal disease (ESRD) may live far away from the closest transplant center, which could compromise their access to kidney transplantation.

Objective:  To assess access to kidney transplantation as a function of distance from the closest transplant center or as a function of rural rather than urban residence.

Design, Setting, and Participants:  Observational study of 699 751 adult patients with kidney failure who had initiated renal replacement in the United States between 1995 and 2007 and were thus placed on a prospective mandatory registry list.

Main Outcome Measures:  Time to placement on the kidney transplant waiting list and time to kidney transplantation, both measured at the start of renal replacement.

Results:  During a median follow-up of 2.0 years (range, 0.0-12.5 years), 122 785 (17.5%) patients received a kidney transplant. Median distance to the closest transplant center was 15 miles. Participants were classified into distance categories by miles from a transplant center with 0 to 15 miles serving as the referent category. Compared with the referent category, the adjusted hazard ratios of deceased or living donor transplantation within each category follows: 16 to 50 miles, 1.03 (95% CI, 1.02-1.05); 51 to 100 miles, 1.11 (95% CI, 1.09-1.12); 101 to 136 miles, 1.14 (95% CI, 1.11-1.17); 137 to 231 miles, 1.16 (95% CI, 1.13-1.20); 232 to 310 miles, 1.20 (95% CI, 1.12-1.28); and more than 310 miles, 1.16 (95% CI, 1.09-1.23). When residence location was classified using rural-urban commuter areas, 79.6% of patients lived in urban; 10.3%, micropolitan; and 10.0%, rural areas. Compared with those living in metropolitan areas, the adjusted hazard ratios of deceased or living donor transplantation among patients residing in micropolitan communities was 1.13 (95% CI, 1.11-1.15) and 1.15 (95% CI, 1.13-1.18) for rural areas. Results were similar for both deceased donor and living donor transplantation and were consistent in multiple sensitivity analyses.

Conclusion:  Remote or rural residence was not associated with increased time to kidney transplantation among people treated for ESRD in the United States.

JAMA. 2009;301(16):1681-1690.

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