Access to quality care impacts patient outcomes, and may be critical both for being listed for liver transplantation (LT) and for long-term post-LT outcomes. Rural residence poses significant challenges for patients with end-stage liver disease (ESLD) seeking LT, as well as for the transplant centre providing care. Rural residence has been suggested to negatively impact outcomes after LT.

AIM To determine the impact of living in a rural (R) or urban (U) community on access to LT and long-term post-LT outcome at a high volume single centre in a single-payer health care system.

METHODS A retrospective analysis was performed of all 2273 LT listings and all 1555 LT performed from 1/1/00 to 8/31/12. R residence was determined using the Canada Post Conversion file with a cut-off point of <1000 inhabitants. Survival was calculated using Log-Rank, while clinical data was analyzed using Chi-square and Mann-Whitney U test.

RESULTS 197 (9%) listed patients came from R and 2076 (91%) from U communities, a listing rate of 14 vs. 23 per million inhabitants per year (p<0.001). Both R and U groups were similar in gender (male 67%vs67%), age (53±10vs53±11 years), median days on waiting list (213vs187 days) at time of transplant, and MELD score at listing (15±7vs16±7 points) and at transplant (19±10vs19±10). Underlying causes of ESLD were comparable, except autoimmune hepatitis, more frequent in R patients (6%vs3%;p=0.03). For 53%R and 43%U transplant candidates, a potential live liver donor stepped forward (p=0.18). 59% of R and 58% of U patients received a LT (p=0.65), while 25% R and 24% U either died on the waiting list or became too sick to be transplanted and were taken off the list (p=0.6). Immediate post-LT outcomes were similar between groups with no significant difference in length of stay or days in ICU (median 14.5R vs 14U, p=0.7; and 2R vs 2U, p=0.4). Graft survival at 1, 3, and 5 years was 90% vs 90%, 86% vs 82%, and 80% vs 78% (R vs U, p=0.79); patient survival was comparable with 93% vs 92%, 83% vs 85%, and 81% vs 79%, respectively (p=0.76).

CONCLUSION In contrast to previous work, our single centre series demonstrated that rural patients may have impaired access to LT listing, but once listed, they have similar likelihood of being transplanted and similar post-operative outcomes. This works suggests efforts needs to be directed to increasing access of rural patients to LT centres, and that rural residence should not negatively impact patient outcome.

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