Original Research

Access to Transplant Care and Services Within the Veterans Health Administration

The VHA provides timely solid organ transplant care and services with outcomes comparable to that of nationally reported estimates.

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References

The Veterans Health Administration (VHA) provides health care services to over 9 million eligible and enrolled veterans out of a US veteran population of 18.9 million.1 In 2014, an Office of Inspector General (OIG) investigation identified timely access to health care within the VHA as a serious concern.2 In direct response, Congress enacted the Veterans Access, Choice, and Accountability Act (VACAA) of 2014 to expand access to care options available to veterans through referral to non-VA community care providers when the veteran is waiting longer than 30 days for an outpatient appointment or services, resides a significant distance (≥ 40 miles) from a VA facility, or experiences an undue burden to receive care and services.3 The VHA also responded, implementing several initiatives to improve veteran access to VHA health care generally, including the MyVA transformation and the proliferation of connected health technology; including telehealth capability and the expanded use of secure messaging. 4-6

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This study examined veterans’ access to the VA transplant program (VATP) for fiscal year (FY 2014 to FY 2016). Timeliness of services and outcomes in relationship to the distance from a VA transplant center (VATC) were evaluated.

Methods

The VATP comprises the following VATCs: 5 heart (Madison, Wisconsin; Nashville, Tennessee; Palo Alto, California; Richmond, Virginia; and Salt Lake City, Utah); 7 kidney (Birmingham, Alabama; Bronx, New York; Houston, Texas; Iowa City, Iowa; Nashville, Tennessee; Pittsburgh, Pennsylvania; and Portland, Oregon); 6 liver (Houston, Texas; Madison, Wisconsin; Nashville, Tennessee; Pittsburgh, Pennsylvania; Portland, Oregon; and Richmond, Virginia); and 2 lung (Madison, Wisconsin; and Seattle, Washington).

In 2012, the VHA published a policy to establish timeliness standards for a VATC initial review decision and referral evaluation.7 In 2013, the VHA National Surgery Office (NSO) implemented a secure intranet-based application called TRACER to facilitate the referral process and track timeliness of initial review decision, evaluation, United Network of Organ Sharing (UNOS) waitlisting, and transplantation.

The referral process is as follows: The referring VA medical facility submits veteran candidate health information into TRACER, selects a VATC, and then TRACER notifies the VATC. The VATC reviews the information and submits an initial review decision as to whether the clinical information supports further evaluation within 48 hours for an emergency referral and 5 business days for a stable referral. If accepted, the VATC completes an evaluation within 30 calendar days of the referral submission date. On evaluation and acceptance, the VATC accepts handoff for transplant-related care, orders additional testing as needed, and waitlists the veteran with UNOS when the clinical status is deemed appropriate.4

The TRACER data from 3 separate cohorts were analyzed from October 1, 2013, to September 30, 2016, with a follow-up event capture through March 31, 2017: (1) the referral cohort, representing all referrals to the VATP; (2) the waitlist cohort, representing those undergoing initial UNOS waitlisting; and (3) the transplant cohort, representing those receiving a solid organ transplant. The straight-line distance between the referring VA medical facility and the VATC was determined for each referral and categorized as follows: less than 100 miles, 100 to 300 miles, 301 to 500 miles, and greater than 500 miles.

Mortality outcomes in the TRACER database were confirmed using the VHA Vital Status file, which combines the Centers for Medicare & Medicaid Services, Social Security Administration, and VHA internal utilization data to determine a best source, including flagging of records that indicate a death date followed by use of VA services.8,9 Records flagged with VA use after death were not considered deaths in this analysis. The NSO regularly refreshes veteran vital status information in the TRACER database for analysis of long-term outcomes.

The analysis methods for this study included Kruskall-Wallis nonparametric 1-way analysis of variance to compare timeliness metrics by distance group, Fine and Gray competing risks models to compare mortality on the UNOS list by distance group, and log-rank and Wilcoxon-Gehan tests to compare patient survival distributions by distance group.10-14 Analysis was generated using SAS software, version 9.4 (Cary, North Carolina) as well as the R statistical software application (r-project.org).15 Publicly available solid organ transplant survival rates were obtained from the Scientific Registry for Transplant Recipients (SRTR).16

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