Impact of Travel Burden and Access to Care on Survival After Pediatric Heart Transplantation in the Contemporary Regionalization Era.

Abstract

During the past decade, complex congenital operations, including heart transplantation (HT), have been increasingly regionalized to high-volume centers (HVCs). Whereas regionalization may increase travel burden and magnify disparities in access to and outcomes after cardiac care, it remains unclear whether center experience mitigates this association. All HT recipients <18 years were tabulated from the 2004-2023 Organ Procurement and Transplantation Network, with follow-up through 2024. The distance between the centroid of the ZIP code of residence and the address of the transplanting hospital was computed by the Haversine formula. Records in the top quartile of travel burden (≥117.8 miles) were considered long distance (others: short distance). Annual hospital volume was computed, with centers performing >12 transplants per year designated HVCs. Of 6857 pediatric HT records, 1661 (24%) comprised long distance. The proportion of those traveling long distances for care increased from 21% in 2004 to 24% in 2023 (P for trend = .002). After risk adjustment, traveling long distances for HT care remained associated with inferior patient (hazard ratio, 1.19; CI, 1.02-1.38) and allograft survival during 10 years (hazard ratio, 1.20; CI, 1.03-1.39). Considering the 2215 patients treated at HVCs, 633 (29%) were long distance. After adjustment and considering only HVC patients, high travel burden was linked with similar patient and allograft outcomes at 10 years. Greater travel burden was associated with inferior patient and allograft survival during 10 post-HT years. Yet, for the patients treated at HVCs, travel distance was not linked with differential outcomes, potentially supportive of ongoing regionalization. Our work highlights the consequences of travel burden on patient survival in the long term.