Many Veterans suffer from chronic kidney disease. When chronic kidney disease reaches its end stage, treatment with dialysis or kidney transplantation becomes necessary. Compared with dialysis, kidney transplantation offers better overall quality of life and life expectancy.
As a result, many Veterans with end-stage kidney disease seek to receive a kidney transplant.
A recent study by our team at the VA Pittsburgh Healthcare System found favorable outcomes for Veterans who receive their post-transplant care in VA versus through Medicare or a combination of VA and Medicare.
Kidney transplants for VA patients
VA established a transplant program in the 1960s that has provided comprehensive organ transplant care to thousands of Veterans. Veterans without non-VA insurance have traditionally been required to travel to regional VA transplant centers to be evaluated for and undergo transplantation.
Recent federal legislation, most notably the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, expanded Veterans’ access to care in the community, including for organ transplantation. As a result, many Veterans can now choose whether they receive transplant care in a VA or a non-VA community transplant center.
In light of the large number of Veterans eligible for community transplant care through the MISSION Act, it is essential that VA understand where Veterans receive their transplant care. This can help determine the resources needed to care for this patient population.
It is also important to understand whether the quality of transplant care differs based on where Veterans receive care.
The study findings
To explore these issues, the VA National Surgery Office and Quality Enhancement Research Initiative (QUERI) partnered with investigators from the VA Center for Health Equity Research and Promotion (CHERP) to explore the impact of community care on transplant-related processes of care and health outcomes.
This study, co-led by myself and fellow CHERP Investigator Dr. Walid Gellad, identified Veterans who underwent kidney transplantation between 2008 and 2016 and were enrolled in both VA and Medicare at the time of their transplant. Consequently, these Veterans had the choice of receiving kidney transplant care at a VA transplant center, a non-VA transplant center using Medicare, or both.
Based on this cohort of Veterans, we sought to answer two key questions:
- Where do Veterans with the choice to receive kidney transplant care within and/or outside VA opt to receive such care?
- Does their choice affect longer-term mortality?
Overall, more than 6,000 Veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in VA and Medicare at the time of the surgery were identified. Among these patients, 16% underwent kidney transplantation within VA and 84% received a kidney outside VA.
In the year following transplantation, 12% received their post-transplant care in VA only, 34% received their post-transplant care outside VA only using Medicare, and 54% received their post-transplant care through both VA and Medicare.
We found that Veterans who received Medicare-only post-transplant care had a higher five-year mortality rate compared with VA-only patients (20% vs. 11%), as did patients who received post-transplant care both within and outside VA (16% vs. 11%).
Implications in the MISSION Act era
This study, which appeared in the Clinical Journal of the American Society of Nephrology, has important implications for Veterans and VA transplantation in the era of the MISSION Act.
First, while most Veterans with the choice to undergo kidney transplantation within or outside VA opt to undergo this surgery in the community, a large proportion choose to use VA, in part or in full, for their post-transplant care.
This suggests that while patterns of transplant care among Veterans may change with the MISSION Act, there will continue to be significant use of VA for key post-transplant care.
Second and most importantly, receipt of all post-transplant care within VA is associated with improved long-term survival compared with receipt of post-transplant care exclusively in the community, or both within and outside VA.
Potential explanation for the findings
One potential explanation for this observation has to do with possible differences in the quality of care provided by VA and community transplant centers. As a nationwide integrated health care system, VA facilitates timely communication and seamless collaboration between providers at transplant centers and smaller facilities and clinics.
Furthermore, VA’s universal electronic medical record facilitates review of laboratory test results and medications prescriptions at any VA facility. These advantages may support better transplant care coordination within a single health care system and lead to more favorable outcomes.
Our team has received additional funding from the VA Health Services Research and Development Service to extend this research. Specifically, we will examine patterns of both kidney and liver transplant care before and after the implementation of the MISSION Act and assess the reasons underlying where Veterans choose to receive kidney and liver transplant care.
We will also broaden the examination of how and why the site of transplant care affects other key outcomes, including time spent on the transplant wait-list, receipt of an organ, and organ failure.
Regardless of the underlying reasons for the more favorable outcomes observed among Veterans who received all of their post-kidney transplant care in VA only, the findings of this research so far should help Veterans and VA providers make evidence-based decisions about where to receive transplant care in the MISSION Act era.
Dr. Steven Weisbord has been a staff nephrologist and core investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System for over 15 years. He has focused his research on management and outcomes of patients with chronic and end-stage kidney disease and the prevention of acute kidney injury.