Veteran Access and Limitations to Organ Recovery (VALOR)

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Abstract: Deceased donors provide lifesaving gifts to patients with chronic organ failure. Organ donation occupies a unique position in American healthcare, as donation care is provided without cost to the patient or their family and is mandated to be provided without bias to age, disability, race, or national origin by federal contractors known as organ procurement organizations (OPOs). Previous regulatory measures of OPO performance did not allow adequate objectivity, reliability, and transparency into procurement practice and have been replaced by a new metric introduced by this study's authors. Analyses using this metric reveal that older persons, minorities, and those living in poor, rural, and remote areas receive lesser access to organ donation. Veterans Administration Medical Centers (VAMCs) represent the largest single hospital system in the United States, and serve a population recognized to be underserved in many aspects of health and medicine. We have developed preliminary data showing that VAMCs recover deceased donor organs at a rate of 4% that of non-VA hospitals. The basis for this disparity is unclear, but given the high concentration of vulnerable and underserved groups at VAMCs, there is a strong imperative to improve donation access for these patients. In this proposal, we will leverage VAMCs' unparalleled electronic health records (EHRs), which offer detailed information on longitudinal patient care and outcomes, to enumerate the potential supply of organ donors nationwide over a 10-year historical period. We will use physiologic, laboratory, and radiographic data to define potential donor quality and estimate transplant yields at varying levels of donation performance relative to non-VA hospitals. We will also interview patients, critical care nurses and physicians at VAMCs, and OPO personnel to gather their experiences and perceptions regarding barriers to more effective donor recovery from these institutions. We will use findings from these qualitative and VA EHR studies to inform a consensus conference on best practices for improved organ donation care at VAMCs in year 2 of our project. Based on the findings of the first two aims in this study, we will create a model for improved VAMC donation care using a large, nationally-representative sample of VAMCs and their attendant OPOs. We will introduce a clinical decision support tool into VA EHR to maximize referral of potential donors. Study staff will integrate with OPOs in responding to VAMC referrals, utilizing VA EHR sources to assist in evaluating patients for donation. Study coordinators will facilitate workflow between VAMC and OPO staff, supporting and monitoring adherence to best practices defined in the consensus conference. We will conduct a follow-up stakeholder meeting to assess perceptions of the pilot program's efficacy among VAMC providers, OPO staff, and veteran and patient advocacy groups from within the study area. Together, this study's findings will not only help to ameliorate disparities in veterans' access to donation care, but will inform efforts to standardize and improve donation care among other underserved populations.