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JAMA. 2008 Jan 9;299(2):202-7. doi: 10.1001/jama.2007.50.

Rates of solid-organ wait-listing, transplantation, and survival among residents of rural and urban areas.

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  • 1Department of Surgery, Dartmouth Medical School, Lebanon, New Hampshire, USA.



Disparities in access to organ transplantation exist for racial minorities, women, and patients with lower socioeconomic status or inadequate insurance. Rural residents represent another group that may have impaired access to transplant services.


To assess the association of rural residence with waiting list registration for heart, liver, and kidney transplant and rates of transplantation among wait-listed candidates.


Five-year US cohort of 174,630 patients who were wait-listed and who underwent heart, liver, or kidney transplantation between 1999 and 2004.


Rates of new waiting list registrations and transplants per million population for residents of 3 residential classifications (rural/small town population, <10,000; micropolitan, 10,000-50,000; and metropolitan >50,000 or suburb of major city).


Compared with urban residents, waiting list registration rates for rural/small town residents were significantly lower for heart (covariate-adjusted rate ratio [RR] = 0.91; 95% confidence interval [CI], 0.86-0.96; P<.002), liver (RR = 0.86; 95% CI, 0.83-0.89; P<.001), and kidney transplants (RR = 0.92; 95% CI, 0.90-0.95; P<.001). Compared with residents in urban areas, rural/small town residents had lower relative transplant rates for heart (RR = 0.88; 95% CI, 0.81-0.94; P = .004), liver (RR = 0.80; 95% CI, 0.77-0.84; P<.001), and kidney transplantation (covariate-adjusted RR = 0.90; 95% CI, 0.88-0.93; P<.001). These disparities were consistent across national organ allocation regions. Significantly longer waiting times among rural patients wait-listed for heart transplantation were observed but not for liver and kidney transplantation. There were no significant differences in posttransplantation outcomes between groups.


Patients living in rural areas had a lower rate of wait-lisiting and transplant of solid organs, but did not experience significantly different outcomes following transplant. Differences in rates of wait-listing and transplant may be due to variations in the burden of disease between different patient groups or barriers to evaluation and waiting list entry for rural residents with organ failure.

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