June 2022

In This Issue: HSR&D Research on Community Care
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Kidney and Liver Transplantation in an Era of Enhanced Community Care

Feature Article

Takeaway: This study will be the first to assess the impact of the MISSION Act on processes and outcomes of kidney and liver transplant care. Information gained from this research will help VA adapt its transplant program to enhance Veterans’ treatment experiences – and to enable Veterans to choose the site of transplant care that optimizes their long-term health.

Historically, many Veterans had to travel long distances to VA medical centers to be evaluated for and undergo kidney or liver transplantation. The ongoing implementation of the MISSION Act will allow many Veterans to undergo kidney or liver transplantation – and to receive post-transplant care in non-VA transplant centers closer to their homes. Investigators recently conducted a study among Veterans dually enrolled in VA and Medicare who underwent kidney transplantation and received post-transplant care to determine the association of the site of transplant care with long-term mortality. The study showed that Veterans who received VA-only post-kidney transplant care had lower five-year mortality compared to non-VA transplant care (11% vs 20%).¹ These findings suggest that the MISSION Act could substantially transform patterns and processes of VA transplant care and unintentionally lead to adverse health outcomes following transplantation.

This ongoing study (May 2021 – April 2025) will examine how the MISSION Act has changed where Veterans receive kidney or liver transplant care (i.e., within VA or community care). It also will determine whether the site of transplant care affects how long they wait for a transplant, their likelihood of receiving an organ, and their health following transplantation. In addition, investigators will explore the perceptions of Veteran patients, VA providers, and administrators on the facilitators and barriers to Veterans’ use of VA for transplant care. Specific aims include:

• Describe temporal patterns of VA and community transplant care (i.e., activation on the wait list, receipt of transplant, and post-transplant management) among Veterans approved for transplantation before and after implementation of the MISSION Act;
• Identify patient and system factors associated with the site where Veterans are wait-listed, undergo transplantation, and receive post-transplant care (VA vs. community vs. dual care); and
• Examine key stakeholders’ (i.e., Veterans, VA providers, VA operations leaders) perceptions of facilitators and barriers to Veterans’ use of VA for kidney and liver transplant care.

Methods

Investigators will link VA data with data from the Scientific Registry of Transplant Recipients (SRTR) to construct a cohort of Veterans enrolled in VA who were activated on the United Network for Organ Sharing (UNOS) wait list for kidney and/or liver transplantation between 7/1/2010 and 6/30/2022. Using this cohort, they will:

• Characterize secular trends in VA and community transplant care,
• Quantitatively assess patient and system factors associated with the site where Veterans undergo transplant and receive post-transplant care, and
• Examine the associations of site of transplant care with key transplant-related outcomes.

They also will conduct semi-structured interviews with Veterans, VA providers, and VA operations leaders to qualitatively assess their perceptions of facilitators and barriers to Veterans’ use of VA for transplant care.

Findings

None to report at this time.

Anticipated Impact

This study will be the first to assess the impact of the MISSION Act on processes and outcomes of kidney and liver transplant care—and the only study to combine VA and SRTR data to characterize the effects of this legislation on Veterans’ transplant care and outcomes. Characterizing the effects of the MISSION Act on VA transplantation is critical to refining policies that govern the VA Transplant Program and allocation of resources to support the delivery of transplant-related care to Veterans with end-stage kidney and/or liver disease. Information gained from this study will help VA adapt its transplant program to enhance Veterans’ treatment experiences and enable Veterans to choose the site of transplant care that optimizes their long-term health.

Study investigators also will continue their partnership with operational leaders in VA’s Office of Community Care and National Surgery Office to design, deploy, and evaluate interventions informed by this research to improve the processes and outcomes of transplant care for Veterans. More broadly, they will disseminate their findings to key stakeholders including Veterans, nephrologists, hepatologists, and transplant surgeons to inform their decision-making regarding the optimal site of transplant and post-transplant care.

Principal Investigator: Steven Weisbord, MD, is part of HSR&D’s Center for Health Equity, Research and Promotion (CHERP).

Publications

1. Cashion W, Gellad W, Sileanu F, et al, 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):437-445.

View study abstract