Patterns, Processes, and Outcomes of Kidney and Liver Transplantation in an Era of Enhanced Community Care for Veterans

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Background: While the VA has provided life-saving organ transplantation to Veterans for decades, critics of the VA Transplant Program claimed that its requirement for Veterans to travel to designated VA Transplant Centers across the nation reduced access to care. The passage of the MISSION Act by Congress in 2018 markedly expanded the number of Veterans eligible to pursue transplantation and post-transplant care in the community. We recently investigated where Veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care and the association of the site of transplant care with long-term mortality. The findings of this work suggest that the MISSION Act could substantially transform patterns and processes of VA transplant care and unintentionally lead to adverse health outcomes following transplantation. Significance/Impact: Characterizing the effects of the MISSION Act on VA transplantation and the factors that influence where Veterans receive transplant care is critical to refine policies governing the VA Transplant Program and allocation of resources to support the delivery of transplant-related care to Veterans with end-stage kidney and/or liver disease. Our study will provide novel insights into how the MISSION Act is affecting patterns and processes of transplant care, as well as outcomes of kidney and liver transplantation among Veterans. Findings from this study will enable Veterans and VA providers to make evidence-based decisions on the source of transplant care that optimizes long-term allograft function and overall survival. Innovation: Our study will be the first to assess the impact of the MISSION Act on processes and outcomes of kidney and liver transplant care and the only study to combine data from the Scientific Registry of Transplant Recipients (SRTR) and the VA Corporate Data Warehouse (CDW) to characterize the effect of this legislation on Veterans’ transplant care and outcomes. Specific Aims. Our specific aims are to: (1) describe temporal patterns of VA and community transplant care (i.e., activation on the wait list, receipt of transplant, and post-transplant management) among Veterans approved for kidney or liver transplantation before and after implementation of the MISSION Act; (2) identify patient and system factors associated with the site Veterans are wait listed for and undergo kidney or liver transplantation and receive post-transplant care (VA vs. community vs. dual); (3) examine the associations of site of: (a) wait listing; (b) transplant surgery; and (c) post-transplant care with key outcomes (i.e., time on the wait list, death on the wait list, receipt of transplant, allograft failure, and mortality) among Veterans approved for kidney or liver transplantation; and (4) qualitatively examine key stakeholders’ (i.e., Veterans, VA providers, VA operations leaders) perceptions of the facilitators of and barriers to Veterans’ use of VA for kidney and liver transplant care. Methodology: We will link SRTR and CDW data to construct a cohort of Veterans enrolled in VA who were activated on the UNOS wait list for kidney and/or liver transplantation between 7/1/2010 and 6/30/2022. Using this cohort, we will characterize secular trends in VA and community transplant care, quantitatively assess patient and system factors associated with the site that Veterans undergo transplant and receive post-transplant care, and examine the associations of site of transplant care with key transplant-related outcomes. We will also conduct semi-structured interviews with Veterans, VA providers, and VA operations leaders to qualitatively assess their perceptions of facilitators and barriers to Veterans’ use of VA for transplant care. Implementation/Next Steps: Our next steps will include: (1) continued partnership with operational leaders in VA’s Office of Community Care and National Surgery Office to design, deploy, and evaluate interventions informed by this research to improve the processes and outcomes of transplant care for Veterans; and (2) broad dissemination of our findings to key stakeholders including Veterans, nephrologists, hepatologists, and transplant surgeons to inform their decision-making regarding the optimal site of transplant and post-transplant care.