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，但批评 退伍军人移植计划声称，它要求退伍军人前往指定的退伍军人移植中心 在全国范围内，获得医疗服务的机会减少了。2018年国会通过的《使命法案》明显 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在退伍军人管理局和联邦医疗保险公司接受肾移植的情况 并接受移植后护理以及移植部位护理与长期死亡率的关联。这个 这项工作的发现表明，使命法可以极大地改变退伍军人管理局的模式和流程 移植护理和非故意导致移植后的不良健康后果。 意义/影响：描述《使命法案》对VA移植的影响和影响因素 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 规划和分配资源，支持向临终退伍军人提供与移植有关的护理 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 和移植护理过程，以及退伍军人肾和肝移植的结果。 这项研究的结果将使退伍军人和退伍军人管理局能够根据证据做出来源决策 移植护理，优化同种异体移植物的长期功能和总体存活率。 创新：我们的研究将第一次评估使命法案对以下过程和结果的影响 肾和肝移植护理和唯一结合移植科学登记数据的研究 接受者(SRTR)和退伍军人事务部企业数据仓库(CDW)来表征这项立法的效果 关于退伍军人的移植护理和结果。 明确的目标。我们的具体目标是：(1)描述退伍军人管理局和社区移植护理的时间模式(即， 等待名单上的激活、移植的接收和移植后的管理) 在《使团法》实施前后进行肾或肝移植；(2)确定患者和 与现场退伍军人相关的系统因素正在等待，并接受肾或肝移植 并接受移植后护理(VA与社区VS DUAL)；(3)检查以下地点的相关性：(A)等待 列出；(B)移植手术；和(C)移植后护理和关键结果(即，在等待名单上的时间，死亡时间 等待名单、移植收据、同种异体移植失败和死亡率)在接受肾脏或肝脏移植的退伍军人中 移植；以及(4)定性检查关键利益相关者(即退伍军人、退伍军人提供者、退伍军人行动 领导人)对退伍军人使用VA进行肾脏和肝脏移植护理的促进者和障碍的看法。 方法：我们将把SRTR和CDW数据联系起来，建立一个退伍军人队列，这些退伍军人在退伍军人中 在2010年7月1日至2022年6月30日期间被列入联合国操作系统肾和/或肝移植等待名单。vbl.使用 在这个队列中，我们将描述退伍军人管理局和社区移植护理的长期趋势，量化评估患者 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， 并检查移植护理地点与关键的移植相关结果之间的关系。我们还将 对退伍军人、退伍军人服务提供商和退伍军人运营负责人进行半结构化访谈，以定性 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/下一步：我们的下一步将包括：(1)继续与 弗吉尼亚州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 受这项研究的启发，改进退伍军人移植护理的过程和结果；以及(2)广泛 将我们的发现传播给主要利益相关者，包括退伍军人、肾病学家、肝病学家和移植 外科医生为他们关于移植和移植后护理的最佳部位的决策提供信息。

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.