Rural Americans are less likely to be put on waiting lists for liver, kidney and heart transplants — and they are less likely to receive those transplants, according to a study published today in the Journal of the American Medical Association.

The study’s authors, doctors at Dartmouth Medical School, found that rural patients were 8 to 15 percent less likely to be put on a waiting list for replacement organs; and rural residents were 10 to 20 percent less likely to receive a transplant. (The percentages vary between heart, kidney and liver transplants.)

There is, in fact, a rather grisly and unequal exchange taking place, Dr. David Axelrod and his co-authors write, as organs taken from deceased rural residents “are mainly transplanted at large urban centers, which leads to a net transfer of organs from rural donors to urban recipients.”


Previous research on transplants had shown “significant barriers” to access to transplant services for racial minorities, women and poor patients. Now, according to the lead author, Dr. David Axelrod, “rural patients with end-stage organ failure may be particularly affected” by the concentration of transplant services in large cities. “For these patients,” the JAMA article said, “lack of access may result in premature or avoidable death.”

The study was based on those placed on the registry of transplant recipients between 1999 and 2004. Patients entered their zip codes, which researchers used to find patients living in urban, small town and rural areas. By the study’s definition, 14 percent of the US population lives in rural America.

Dr. Axelrod and his co-authors then checked to see if the number of those wait-listed and those who received transplants reflected the total population of these three areas. They didn’t. Urban residents were significantly more likely to be placed on the waiting list and to receive transplants than those living in small towns or rural areas.

Previous studies have found that the process of doctor referrals, tests and evaluations tended to exclude African-Americans, women and poor patients disproportionately. There have been efforts to rectify these disparities, but nothing is being done currently to reduce the barriers to care faced by rural patients.

As transplant facilities continue to concentrate in larger urban areas, the authors warned the rural/urban disparity could continue to grow.

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