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

背景：虽然退伍军人管理局几十年来一直为退伍军人提供挽救生命的器官移植，但 VA移植计划声称，其要求退伍军人前往指定的VA移植中心， 全国范围内的医疗服务减少。2018年国会通过的《使命法案》 扩大了有资格在社区进行移植和移植后护理的退伍军人人数。 我们最近调查了退伍军人双重参加VA和Medicare的退伍军人接受肾移植的情况 并接受移植后护理以及移植护理部位与长期死亡率的相关性。的 这项工作的结果表明，《使命法案》可以实质性地改变退伍军人事务的模式和过程 移植护理和无意中导致移植后的不良健康结果。 意义/影响：描述使命法案对VA移植的影响以及影响VA移植的因素。 影响退伍军人接受移植护理的地方对于完善管理VA移植的政策至关重要 计划和资源分配，以支持向终末期退伍军人提供移植相关护理 肾脏和/或肝脏疾病。我们的研究将为《使命法案》如何影响模式提供新的见解 和移植护理的过程，以及退伍军人肾脏和肝脏移植的结果。 这项研究的结果将使退伍军人和VA提供者能够对来源做出基于证据的决定 移植护理，优化长期同种异体移植功能和总生存率。 创新：我们的研究将是第一个评估使命法案对过程和结果的影响的研究。 肾脏和肝脏移植护理，也是唯一一项结合移植科学登记处联合收割机数据的研究 收件人（SRTR）和VA公司数据仓库（CDW），以描述该立法的影响 关于退伍军人的移植护理和结果。 具体目标。我们的具体目标是：（1）描述VA和社区移植护理的时间模式（即， 在等待名单上激活，接受移植，以及移植后管理） （2）在实施《使命法》之前和之后进行肾或肝移植;（3）确定患者和 与该地点相关的系统因素退伍军人正在等待并接受肾脏或肝脏移植 并接受移植后护理（VA vs.社区vs.双重）;（3）检查以下部位的相关性：（a）等待 列表;（B）移植手术;和（c）具有关键结果的移植后护理（即，等待名单上的时间，死亡 等待名单、接受移植、移植失败和死亡率） 移植;以及（4）定性地检查关键利益相关者的（即，退伍军人，VA提供者，VA操作 领导人）的看法的促进者和障碍，退伍军人使用VA的肾脏和肝脏移植护理。 方法：我们将SRTR和CDW数据联系起来，构建一个在VA注册的退伍军人队列， 在2010年7月1日至2022年6月30日期间在UNOS等待名单上激活肾脏和/或肝脏移植。使用 在这个队列中，我们将描述VA和社区移植护理的长期趋势，定量评估患者 以及与退伍军人接受移植和接受移植后护理的地点相关的系统因素， 并检查移植护理部位与关键移植相关结果的关联。我们还将 对退伍军人、退伍军人管理机构和退伍军人管理业务负责人进行半结构化访谈， 评估他们对退伍军人使用VA进行移植护理的促进者和障碍的看法。 实施/后续步骤：我们的后续步骤将包括：（1）继续与运营领导者合作， VA的社区护理办公室和国家外科办公室设计，部署和评估干预措施 通过这项研究，以改善退伍军人移植护理的过程和结果;（2）广泛 将我们的研究结果传播给关键利益相关者，包括退伍军人、肾病学家、肝病学家和移植 外科医生告知他们关于最佳移植部位和移植后护理的决策。

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.