Access to Transplant Care and Services Within the Veterans Health Administration
Discussion
This study shows that the VATP delivers timely, high-quality care and services even when the veteran’s referring VA medical facility is located a considerable distance from the VATC. Three separate cohorts of veterans were examined for the FY 2014 to FY 2016 study period: those referred, those waitlisted, and those transplanted. The referral cohort identified 6,009 referral submissions, performed 3,500 evaluations on veterans deemed to be potential candidates for solid organ transplantation, and placed 2,137 of these referrals on the UNOS waitlist. The median time from referral to initial review decision was 5 hours for emergency referrals and 3 business days for stable referrals. The median time from referral to evaluation was 27 calendar days, and the median time from referral to UNOS waitlisting was 78 calendar days. Improvements in timeliness for referral initial review decision, evaluation completion, and waitlisting over the study period were reflective of VHA and NSO efforts to enhance access to services. In FY 2016, 100% of emergency referrals received an initial review decision within 48 hours, 91.4% of stable reviews received an initial review decision within 5 business days, and 86.9% of all referrals underwent evaluation within 30 calendar days.
Distance of less than 100 miles between the referring VA medical facility and the VATC was associated with statistically significant shorter times for initial review decision, evaluation, and UNOS waitlisting. Referrals from less than 100 miles were a minority (9.6%) of referrals and most often represented a direct referral from the VATC to its own program. Timeliness of referral initial review decision, evaluation, or UNOS waitlisting was similar for distance categories greater than 100 miles: 100 to 300 miles, 301 to 500 miles, or greater than 500 miles.
The waitlist cohort identified 2,265 veterans, of which 731 (32.3%) underwent transplantation and 226 (10.0%) died. All-cause mortality for veterans once waitlisted, whether or not maintained on the UNOS waitlist, varied among organs and was found to be 6.1% for heart, 5.9% for kidney, 19.0% for liver, and 11.5% for lung. Waitlist mortality and the time from referral to solid organ transplant was similar for all distance categories.
The transplant cohort identified 947 veterans receiving a solid organ transplant with a median time from referral to transplant that varied considerably by organ type; 301 days (10.0 mo) for heart transplants, 914 days (30.5 mo) for kidney transplants, 236 days (7.9 mo) for liver transplants, and 246 days (8.2 mo) for lung transplants. Time to transplant and posttransplant survival were similar in all distance categories. Moreover, the VATP 1-year survival rates compared favorably with published SRTR data.
Prior studies have shown that distance to a transplant center adversely impacts access to transplant services, mortality on the UNOS waitlist, and transplant outcomes.17-21 Patients living in small towns and isolated rural regions were 8% to 15% less likely to be waitlisted and 10% to 20% less likely to undergo heart, kidney, and liver transplantation than were patients in urban environments.17 This study found that a referral to the VATP from a VA medical facility located less than 100 miles from the VATC received an evaluation 5 to 7 days sooner and be placed on the UNOS waitlist 21 to 29 days sooner than a veteran referred to a VATC located at least 100 miles away. Contrary to prior studies, the distance from the VATC did not have an adverse impact on UNOS waitlist mortality, time to transplantation, or survival outcomes posttransplant.
The VHA offers a number of advantages to the veteran in need of transplant care and services. The VHA is the largest integrated health care system in the US designed specifically for veterans and their complex and specific needs with greater than 1,200 points of care and a single electronic health record optimizing coordinated services.22 In addition, the VHA’s use of telehealth to expedite evaluations and follow-up transplant care closer to home thereby obviating the need for travel. The VHA also has an electronic process to facilitate referral and tracking of timeliness of care (TRACER). Finally, VHA has policies that supports travel benefits, including lodging for the veteran, caregiver, and living donor if applicable for evaluations, transplant procedures, and follow-up care.4,23
The coordination of health care services in a single integrated health care system may be the most significant advantage.24 Multiple studies have examined dual care, representing care and services provided across 2 separate health care systems, showing an association between dual care and an increased risk of hospitalization, duplication of tests, rates for prescribing potentially unsafe medications, and mortality.25-27 Although no study to date is on point, it is reasonable to imply that dual care imposes unnecessary risks to the veteran receiving complex lifelong transplant care when the VATP is shown to provide timely and high-quality care.
