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2023 HSR&D/QUERI National Conference Abstract

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1140 — Non-White Veterans Likely Face Barriers to Accessing Lung Transplant Evaluation Not Faced by White Veterans

Lead/Presenter: Matthew Griffith
All Authors: Griffith MF (Seattle-Denver VA HSR&D Center of Innovation, VA Eastern Colorado Health Care System, Aurora, CO), Colon-Hidalgo DA (University of Colorado Anschutz Medical Campus, Aurora, CO) Ayele RA (Seattle-Denver VA HSR&D Center of Innovation, VA Eastern Colorado Health Care System, Aurora, CO) Kelley, LR (Seattle-Denver VA HSR&D Center of Innovation, VA Eastern Colorado Health Care System, Aurora, CO)

Objectives:
Veterans with advanced stage tobacco-related chronic lung diseases (e.g., chronic obstructive pulmonary disease) or autoimmune, occupational, or environmental lung diseases (e.g., idiopathic pulmonary fibrosis) can receive lung transplantation through the Veterans Health Administration (VA). Since 2005, all patients awaiting transplant have been assigned a lung allocation score (LAS). A higher score on the 0-100 point scale reflects more advanced stage disease and therefore assigns a higher priority. Prior studies have found that non-White patients listed for lung transplant have initial LAS scores that are higher than White patients (indicating more advanced stage disease at time of listing), suggesting barriers to accessing the lung transplant system. We sought to determine whether similar barriers existed in the VA system.

Methods:
We were provided with the Thoracic dataset by the Organ Procurement and Transplantation Network (OPTN) administrated by the United Network for Organ Sharing (UNOS) that included data collected from all recipients and donors of heart and lung transplants. We limited our evaluation to patients listed for initial lung transplant between 2005-2020. We used the primary projected payer to identify transplants provided through the VA system and used the racial/ethnic identity assigned by UNOS. We performed bivariate tests of significance comparing Veterans to non-Veterans and White Veterans to non-White Veterans. Linear and logistic models were created to evaluate post-listing care quality, adjusted for initial LAS score.

Results:
Among the 33,732 individuals listed for initial lung transplant, 450 (1%) had the VA listed as the primary projected payer with private insurance, Medicare, and Medicaid accounting for 51%, 37% and 8% respectively. These Veterans were primarily white (80%) and male (80%). VA patients had lower initial LAS scores (40 vs 42), were older (58y vs 56y) and were more likely to be listed for COPD (35% vs 21%) than non-VA patients. Non-white Veterans had higher initial LAS scores (46 v 39), were younger (55y v 59y), were more likely to be non-smokers (46% v 17%) and were less likely to be listed for tobacco related lung diseases (12% vs 40%) than White Veterans. Initial LAS scores were lower for White Veterans than White non-Veterans (39 v 41), but similar between non-White Veterans and non-Veterans (46 v 45). Race was not associated with waitlist time, death prior to transplant, or survival time following transplant.

Implications:
Although overall Veterans in the VA system are listed for lung transplant with less advanced disease than non-Veterans, non-White Veterans do not appear to benefit from this relative advantage in care access and quality. These Veterans are listed with more advanced stage disease, despite being younger and less likely to smoke. Lower rates of listing for tobacco-related lung diseases among non-White individuals listed for transplant could suggest underdiagnosis of these conditions or intersectionality of bias affecting these individuals. Once listed for transplant, race is not associated with care quality.

Impacts:
The VA healthcare system must examine barriers to lung transplant evaluation for non-White individuals, particularly those with a history of tobacco use who may face additional bias due to intersectionality of race and tobacco use.