Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant

Objective: To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation. Study design: This was an observational study of all pediatric patients (aged <19 years) who received a liver transplant between January 1, 2005, and December 31, 2015 in the US, with follow-up through January 2019 (N = 5964). One hundred ninety-five patients whose home ZIP code could not be matched to primary care shortage area status were excluded. The primary outcome was a composite endpoint of graft failure or death. We used Cox proportional hazards to model the associations between health professional shortage area (HPSA) and graft failure/death. Results: Children living in HPSAs had lower estimated graft survival rates at 10 years compared with those not in HPSAs (76% vs 80%; P <.001). In univariable analysis, residence in an HPSA was associated with a 22% higher hazard of graft failure/death than non-residence in an HPSA (hazard ratio [HR], 1.22; 95% CI, 1.09-1.36; P <.001). Black children from HPSAs had a 67% higher hazard of graft failure/death compared with those not in HPSAs (HR, 1.67; 95% CI, 1.29 to 2.16; P =.006); the effect of HPSA status was less pronounced for White children (HR, 1.11; 95% CI, 0.98-1.27; P =.10). Conclusions: Children living in primary care shortage areas are at increased risk of graft failure and death after liver transplant, and this risk is particularly salient for Black children. Future work to understand how living in these regions contributes to adverse outcomes may enable teams to mitigate this risk for all children with chronic illness.