A survey of healthcare facility location

Under the current liver-transplantation policy, donor organs are offered to patients with the highest risk of death. Using data derived from all adult candidates for primary liver transplantation who were registered with the Organ Procurement and Transplantation Network in 2005 and 2006, we developed and validated a multivariable survival model to predict mortality at 90 days after registration. The predictor variable was the Model for End-Stage Liver Disease (MELD) score with and without the addition of the serum sodium concentration. The MELD score (on a scale of 6 to 40, with higher values indicating more severe disease) is calculated on the basis of the serum bilirubin and creatinine concentrations and the international normalized ratio for the prothrombin time. In 2005, there were 6769 registrants, including 1781 who underwent liver transplantation and 422 who died within 90 days after registration on the waiting list. Both the MELD score and the serum sodium concentration were significantly associated with mortality (hazard ratio for death, 1.21 per MELD point and 1.05 per 1-unit decrease in the serum sodium concentration for values between 125 and 140 mmol per liter; P<0.001 for both variables). Furthermore, a significant interaction was found between the MELD score and the serum sodium concentration, indicating that the effect of the serum sodium concentration was greater in patients with a low MELD score. When applied to the data from 2006, when 477 patients died within 3 months after registration on the waiting list, the combination of the MELD score and the serum sodium concentration was considerably higher than the MELD score alone in 32 patients who died (7%). Thus, assignment of priority according to the MELD score combined with the serum sodium concentration might have resulted in transplantation and prevented death. This population-wide study shows that the MELD score and the serum sodium concentration are important predictors of survival among candidates for liver transplantation. 2008 Massachusetts Medical Society

Despite spending more than any other nation on medical care per person, the United States ranks behind other industrialized nations in key health performance measures. A main cause is the deep disparities in access to care and health outcomes. Federal programs such as the designations of Medically Underserved Areas/Populations and Health Professional Shortage Areas are designed to boost the number of health professionals serving these areas and to help alleviate the access problem. Their effectiveness relies first and foremost on an accurate measure of accessibility so that resources can be allocated to truly needy areas. Various measures of accessibility need to be integrated into one framework for comparison and evaluation. Optimization methods can be used to improve the distribution and supply of health care providers to maximize service coverage, minimize travel needs of patients, limit the number of facilities, and maximize health or access equality. Inequality in health care access comes at a personal and societal price, evidenced in disparities in health outcomes, including late-stage cancer diagnosis. This review surveys recent literature on the three named issues with emphasis on methodological advancements and implications for public policy.