Skip to main content

Advertisement

SpringerLink
Log in

County Rankings Have Limited Utility When Predicting Liver Transplant Outcomes

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Evidence of geographical differences in liver transplantation (LT) outcomes has been proposed as a reason to include community characteristics in risk adjustment of transplant quality metrics. However, consistency and utility of rankings in LT outcomes for counties have not been demonstrated.

Aims

We sought to evaluate the utility of county rankings (county socioeconomic status (SES) or county health scores (CHS)) on outcomes after LT.

Methods

Using the United Network for Organ Sharing Registry, adults ≥ 18 years of age undergoing LT between 2002 and 2014 were identified. County-specific 1-year survival was calculated using the Kaplan–Meier method for counties with ≥ 5 LT performed during this period. Agreement between high-risk designation by 1-year mortality rate and county ranking was calculated using the Spearman correlation coefficient.

Results

The analysis included 47,769 LT recipients in 1092 counties. County 1-year mortality rates were not correlated with county CHS (Spearman ρ = 0.01, p = 0.694) or county SES (Spearman ρ = − 0.01, p = 0.734). After controlling for individual-level covariates, a statistically significant variability in mortality hazards across counties (p < 0.001) persisted. Although both CHS and SES measures improved the model fit (p = 0.004 and p = 0.048, respectively), an unexplained residual variation in mortality hazard across counties continued.

Conclusions

There is poor agreement between county rankings on various socioeconomic indicators and LT outcomes. Although there is variability in outcomes across counties, this appears not to be due to county-level socioeconomic indices.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

LT:

Liver transplantation

SES:

Socioeconomic status

CHS:

County health scores

NQF:

National Quality Forum

DHHS:

Department of Health and Human Services

ACS:

American Community Survey

ESLD:

End-stage liver disease

MELD:

Model for end-stage liver disease

US:

United States

UNOS:

United Network for Organ Sharing

DRI:

Donor risk index

LOS:

Length of stay

HR:

Hazard ratios

CI:

Confidence interval

References

  1. Bennett KM, Scarborough JE, Pappas TN, Kepler TB. Patient socioeconomic status is an independent predictor of operative mortality. Ann Surg. 2010;252:552–558.

    PubMed  Google Scholar 

  2. Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013;216:482–492.e412.

    Article  Google Scholar 

  3. National Quality Forum. Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors. Risk Adjustment and SES. 2014.

  4. Duda L. National Organ Allocation Policy: The final rule. Virtual Mentor 2005;7:604–607.

    Google Scholar 

  5. Ellison MD, Edwards LB, Edwards EB, Barker CF. Geographic differences in access to transplantation in the United States. Transplantation. 2003;76:1389–1394.

    Article  Google Scholar 

  6. Adler JT, Yeh H. Social determinants in liver transplantation. Clin Liver Dis. 2016;7:15–17.

    Article  Google Scholar 

  7. Adler JT, Bababekov YJ, Markmann JF, Chang DC, Yeh H. Distance is associated with mortality on the waitlist in pediatric liver transplantation. Pediatr Transplant. 2017;21:e12842.

    Article  Google Scholar 

  8. Yeh H, Smoot E, Schoenfeld DA, Markmann JF. Geographic inequity in access to livers for transplantation. Transplantation. 2011;91:479–486.

    PubMed  PubMed Central  Google Scholar 

  9. Yoo HY, Thuluvath PJ. Outcome of liver transplantation in adult recipients: influence of neighborhood income, education, and insurance. Liver Transplant. 2004;10:235–243.

    Article  Google Scholar 

  10. Quillin RC III, Wilson GC, Wima K, et al. Neighborhood level effects of socioeconomic status on liver transplant selection and recipient survival. Clin Gastroenterol Hepatol. 2014;12:1934–1941.

    Article  Google Scholar 

  11. Schold JD, Phelan MP, Buccini LD. Utility of ecological risk factors for evaluation of transplant center performance. Am J Transplant. 2017;17:617–621.

    Article  CAS  Google Scholar 

  12. Miller R, Akateh C, Thompson N, et al. County socioeconomic characteristics and pediatric renal transplantation outcomes. Pediatr Nephrol. 2018;33:1227–1234.

    Article  Google Scholar 

  13. Ross K, Patzer RE, Goldberg DS, Lynch RJ. Sociodemographic determinants of waitlist and posttransplant survival among end-stage liver disease patients. Am J Transplant. 2017;17:2879–2889.

    Article  CAS  Google Scholar 

  14. County Health Rankings and Roadmaps. http://www.countyhealthrankings.org/rankings/data. Published 2017.

  15. Roux AVD, Merkin SS, Arnett D, et al. Neighborhood of residence and incidence of coronary heart disease. N Engl J Med. 2001;345:99–106.

    Article  Google Scholar 

  16. Bureau UC. American Community Survey Data Releases. 2017.

  17. Feng S, Goodrich NP, Bragg-Gresham JL, et al. Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant. 2006;6:783–790.

    Article  CAS  Google Scholar 

  18. Beal EW, Black SM, Mumtaz K, et al. High center volume does not mitigate risk associated with using high donor risk organs in liver transplantation. Dig Dis Sci. 2017;62:2578–2585. https://doi.org/10.1007/s10620-017-4639-2.

    Article  PubMed  Google Scholar 

  19. Tumin D, Horan J, Shrider EA, et al. County socioeconomic characteristics and heart transplant outcomes in the United States. Am Heart J. 2017;190:104–112.

    Article  Google Scholar 

  20. Singh TP, Gauvreau K. Center effect on post-transplant survival among currently active United States pediatric heart transplant centers. Am J Transplant. 2018;18:2914–2923.

    Article  Google Scholar 

  21. DuBay DA, MacLennan PA, Reed RD, et al. Insurance type and solid organ transplantation outcomes: a historical perspective on how medicaid expansion might impact transplantation outcomes. J Am Coll Surg. 2016;223:611–620.e614.

    Article  Google Scholar 

  22. Johnson AM, Johnson A, Hines RB, Bayakly R. The effects of residential segregation and neighborhood characteristics on surgery and survival in patients with early-stage non-small cell lung cancer. Cancer Epidemiol Biomark Prev. 2016;25:750.

    Article  CAS  Google Scholar 

  23. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, et al. Us county-level trends in mortality rates for major causes of death, 1980–2014. JAMA. 2016;316:2385–2401.

    Article  Google Scholar 

  24. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs R, et al. Inequalities in life expectancy among US Counties, 1980 to 2014 temporal trends and key drivers. JAMA Intern Med. 2017;177:1003–1011.

    Article  Google Scholar 

  25. Foraker RE, Rose KM, Kucharska-Newton AM, Ni H, Suchindran CM, Whitsel EA. Variation in rates of fatal coronary heart disease by neighborhood socioeconomic status: the atherosclerosis risk in communities surveillance (1992–2002). Ann Epidemiol. 2011;21:580–588.

    Article  Google Scholar 

  26. Schold JD, Heaphy ELG, Buccini LD, et al. Prominent impact of community risk factors on kidney transplant candidate processes and outcomes. Am J Transplant. 2013;13:2374–2383.

    Article  CAS  Google Scholar 

  27. Akateh C, Tumin D, Beal EW, et al. Change in health insurance coverage after liver transplantation can be associated with worse outcomes. Dig Dis Sci. 2018;63:1463–1472. https://doi.org/10.1007/s10620-018-5031-6.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Beal EW, Tumin D, Mumtaz K, et al. Factors contributing to employment patterns after liver transplantation. Clin Transplant. 2017;31:e12967.

    Article  Google Scholar 

  29. Kemmer N, Zacharias V, Kaiser TE, Neff GW. Access to liver transplantation in the MELD era: role of ethnicity and insurance. Dig Dis Sci. 2008;54:1794. https://doi.org/10.1007/s10620-008-0567-5.

    Article  PubMed  Google Scholar 

  30. Barshes NR, Becker NS, Washburn WK, Halff GA, Aloia TA, Goss JA. Geographic disparities in deceased donor liver transplantation within a single UNOS region. Liver Transplant. 2007;13:747–751.

    Article  Google Scholar 

  31. Goldberg DS, French B, Forde KA, et al. Association of distance from a transplant center with access to waitlist placement, receipt of liver transplantation, and survival among us veterans. JAMA. 2014;311:1234–1243.

    Article  CAS  Google Scholar 

Download references

Funding

This research was supported by the NIH T32AI 106704-05 training Grant.

Author information

Authors and Affiliations

  1. Division of General and Gastrointestinal Surgery, Department of Surgery, Ohio State University Wexner Medical Center, Faculty Tower, 395 W 12th Ave, Room 654, Columbus, OH, 43210-1267, USA

    Clifford Akateh & Eliza W. Beal

  2. Division of Transplantation, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Clifford Akateh, Eliza W. Beal & Sylvester M. Black

  3. Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, 27834, USA

    Dmitry Tumin

  4. Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA

    Don Hayes Jr.

  5. Section of Pulmonary Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, 43205, USA

    Don Hayes Jr.

  6. Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, 43205, USA

    Rebecca Miller & Joseph D. Tobias

  7. Department of Anesthesiology and Pain Medicine, Ohio State University Wexner Medical Center, Columbus, OH, 43205, USA

    Joseph D. Tobias

  8. Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, 43210, USA

    Don Hayes Jr.

Authors
  1. Clifford Akateh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rebecca Miller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eliza W. Beal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dmitry Tumin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joseph D. Tobias
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Don Hayes Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sylvester M. Black
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Clifford Akateh.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Disclaimer

The data reported in this manuscript were supplied by the United Network for Organ Sharing as the contractor for the Organ Procurement and Transplantation Network. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the OPTN or the US Government.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Akateh, C., Miller, R., Beal, E.W. et al. County Rankings Have Limited Utility When Predicting Liver Transplant Outcomes. Dig Dis Sci 65, 104–110 (2020). https://doi.org/10.1007/s10620-019-05734-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-019-05734-z

Keywords

Search

Navigation