Veterans Receiving VA-Only Post-Kidney Transplant Care Had Lower Five-Year Mortality Compared to Non-VA Transplant Care
BACKGROUND:
The MISSION Act will substantially increase the number of Veterans who are eligible for organ transplant care outside VA, but there are no data on how this will affect patient outcomes following transplantation. To gauge the potential effect of the MISSION Act on Veterans, investigators conducted a retrospective cohort study to characterize where Veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care – and to evaluate the association of post-transplant care source with longer-term mortality. Investigators used VA and Medicare data to identify all Veterans dually enrolled in VA and Medicare who underwent kidney transplantation between January 1, 2008 and December 31, 2016. Overall, 6,206 Veterans met eligibility criteria, of whom 975 (16%) underwent kidney transplantation at a VA Transplant Center and 5,231 (84%) at a non-VA Transplant Center through Medicare.
FINDINGS:
- In the first year following transplantation, 752 Veterans (12%) received post-transplant care in VA only, 2,092 (34%) through Medicare only, and 3,362 (54%) through both VA and Medicare.
- Veterans who received VA-only post-transplant care had the lowest 5-year mortality compared to those receiving such care via Medicare or both VA and Medicare.
- Over 5 years of follow-up, 1,053 Veterans (17%) died overall. Patients who received Medicare-only post-transplant care had a higher 5-year mortality rate compared with VA-only patients (20% v. 11%), as did dual care patients (16% v. 11%). There also was lower 30-day mortality among those transplanted within VA compared to outside VA (<1% v. 1.3%).
- The need for dialysis at one year was lower in Veterans who received VA-only post-transplant care than Medicare only (2% v. 3%) and dual care (2% v. 4%).
IMPLICATIONS:
- These findings can inform patient decisions regarding the preferred venue of care following kidney transplantation and highlight the critical importance of monitoring patient outcomes as VA expands options for care in the community via the MISSION Act and other healthcare legislation.
LIMITATIONS:
- Investigators did not have access to data on post-transplant care paid for by private insurance and hence, did not include Veterans who were eligible for but not enrolled in VA.
- Investigators did not have access to some donor data (i.e., type of donor - standard criteria vs. extended criteria); differences in such variables, if present, could affect longer-term outcomes.
- Medicare policies from 2008-2016 may not reflect current policies regarding care outside the VA
AUTHOR/FUNDING INFORMATION:
This study was partly funded by VA HSR&D’s Quality Enhancement Research Initiative (QUERI). Drs. Gellad, Sileanu, Mor, Fine, Hale, Hall, Rogal, Switzer, and Weisbord are with HSR&D’s Center for Health Equity, Research and Promotion (CHERP), and Dr. Wang is part of HSR&D’s Center to Accelerate Discovery and Practice Transformation (ADAPT). Drs. Bronson, Wilson, and Gunnar are with VHA in Washington, DC.
Cashion W, Gellad W, Sileanu F, Mor M, Fine M, Hale J, Hall D, Rogal S, Switzer G, Ramkumar M, Wang V, Bronson D, Wilson M, Gunnar W, and Weisbord S. Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare. Clinical Journal of the American Society of Nephrology. March 8, 2021;16(3):437-45.
