*Purpose: While specific clinical characteristics known to impact lung transplant waitlist mortality and proximity to the transplant center have been associated with outcomes in other cohorts, the interplay between distance to the transplant center and community characteristics has not been described in relation to lung transplant waitlist mortality. This study evaluated relationships between community characteristics and distance to the transplant center in adult lung transplant candidates after adjusting for clinical variables known to affect waitlist mortality.

*Methods: Principal components analysis of national zip code and county-level data utilizing American Community Survey, Institute for Health Metrics and Evaluation and County Health Rankings databases yielded 8 community-level components. Distances between listing centers and candidates’ residences were computed via zip codes, latitude and longitude. Standardized community-level component scores and patient distances were linked to Scientific Registry of Transplant Recipient candidate records that were supplemented with zip codes. A cumulative incidence competing risk survival model evaluated the association of component scores and patient-level characteristics with waitlist mortality/delisting due to being too ill (competing event, transplantation).

*Results: The sample included 28,464 adults on the waitlist 2005-2017. After adjusting for clinical characteristics, candidates residing in communities characterized by lower educational attainment, limited financial resources and more persons engaged in occupations that are traditionally non-professional (HR=1.08, 95%CI=1.03-1.13, P=.002) and distance to transplant center >250 miles (HR=1.16, 95%CI=1.01-1.34 vs ≤25 miles, P=.039) were independently associated with increased waitlist mortality. Examples of other variables adjusted for in the model, and known to be associated with increased waitlist mortality, included being underweight, prostacyclin and ventilator support, and functional status requiring total assistance (all P≤0.023).

*Conclusions: Patients residing in communities characterized by lower educational attainment, limited financial resources, and a predominance of non-professional occupations as well as those who live >250 miles from the transplant center are at increased risk of death while on the lung transplantation waitlist. These findings may further inform transplant centers that are developing outreach clinics in rural communities and impact distribution of resources related to waitlist management.

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