Introduction: The impact of local provision of specialty service on patients' access to care was studied in Canada's 13 health care jurisdictions where distance may be a barrier limiting access. Methods: A cross-sectional study of routinely collected registry data in Ontario and Nova Scotia was performed. Liver transplant was chosen as an indicator service. Transplant rate, disease severity, urgency and outcome were studied in adult recipients of first liver transplants from 1993 to 2002. Provinces that provided liver transplants were compared with those that did not; Ontario regions that provided the service were compared with those that did not; and the period of time when liver transplants were available in Nova Scotia was compared with the time when they were not. Results: Use varied widely between jurisdictions but was consistently higher in provider provinces, at 10.9 per million population (pmp) compared with 8.9 pmp in nonprovider provinces (p