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.

Fed Pract. 2018 August;35(8):12-21

Author(s):

William Gunnar, MD, JD

Douglas A. Bronson, PhD

Sandra A. Cupples, PhD, RN

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References

1. US Department of Veterans Affairs, National Center for VeteransAnalysis and Statistics. Profile of veterans: 2015: data from the American Community Survey. https://www.va.gov/VETDATA/DOCS/SPECIALREPORTS/PROFILE_OF_VETERANS_2015.PDF. Published March 2017. Accessed July 2, 2018.

2. US Department of Veterans Affairs, Office of the Inspector General. Review of alleged patient deaths, patient wait times, and scheduling practices at the Phoenix VA Health Care System. https://www.va.gov/OIG/PUBS/VAOIG-14-02603-267.PDF. Published August 26, 2014. Accessed July 2, 2018.

3. US Department of Veterans Affairs. VHA directive 1700: Veterans Choice Program. https://www.va.gov/VHAPUBLICATIONS/VIEWPUBLICATION.ASP?PUB_ID=3287. Published October 25, 2016. Accessed July 2, 2018.

4. US Department of Veterans Affairs. MyVA. https://www.va.gov/MYVA. Updated November 8, 2016. Accessed July 2, 2018.

5. US Department of Veterans Affairs. Telehealth services. https://www.telehealth.va.gov. Updated March 27, 2017. Accessed July 2, 2018.

6. US Department of Veterans Affairs. Secure messaging. My HealtheVet. https://www.myhealth.va.gov/MHV-PORTAL-WEB/SECURE-MESSAGING-SPOTLIGHT. Updated July 1, 2016. Accessed July 2, 2018.

7. US Department of Veterans Affairs, Veterans Health Administration. VHA directive 2012-018: Solid organ and bone marrow transplantation. Published July 9, 2012.

8. Page WF, Mahan CM, Kang HK. Vital status ascertainment through the files of the Department of Veterans Affairs and the Social Security Administration. Ann Epidemiol. 1996;6(2):102-109.

9. Sohn M-W, Arnold N, Maynard C, Hynes DM. Accuracy and completeness of mortality data in the Department of Veterans Affairs. Popul Health Metr. 2006;4:2.

10. Kruskal WH, Wallis WA. Use of ranks in one-criterion variance analysis. J Am Stat Assoc. 1952;47(260):583-621.

11. Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc. 1999;94(446):496-509.

12. Peto R, Peto J. Asymptotically efficient rank invariant test procedures. J R Stat Soc Ser A Stat Soc. 1972;135(2):185-207.

13. Gehan EA. A generalized Wilcoxon test for comparing arbitrarily singly-censored samples. Biometrika. 1965;52(1/2):203-223.

14. Lee ET, Desu MM, Gehan EA. A Monte Carlo study of the power of some two-sample tests. Biometrika. 1975;62(2):425-432.

15. The R Foundation. The R project for statistical computing. https://www.r-project.org. Accessed July 2, 2018.

16. Scientific Registry of Transplant Recipients. https://www.srtr.org. Accessed July 2, 2018.

17. Axelrod DA, Guidinger MK, Finlayson S, et al. Rates of solid-organ wait-listing, transplantation, and survival among residents of rural and urban areas. JAMA. 2008;299(2):202-207.

18. Thabut G, Munson J, Haynes K, Harhay MO, Christie JD, Halpern SD. Geographic disparities in access to lung transplantation before and after implementation of the lung allocation score. Am J Transplant. 2012;12(11):3085-3093.

19. Zorzi D, Rastellini C, Freeman DH, Elias G, Duchini A, Cicalese L. Increase in mortality rate of liver transplant candidates residing in specific geographic areas: analysis of UNOS data. Am J Transplant. 2012;12(8):2188-2197.

20. Goldberg DS, French B, Forde KA, et al. Association of distance from a transplant center with access to waitlist placement, receipt of liver transplantation, and survival among US veterans. JAMA. 2014;311(12):1234-1243.

21. Cicalese L, Shirafkan A, Jennings K, Zorzi D, Rastellini C. Increased risk of death for patients on the waitlist for liver transplant residing at greater distance from specialized liver transplant centers in the United States. Transplantation. 2016;100(10):2146-2152.

22. US Department of Veterans Affairs. About VHA. https://www.va.gov/health/aboutvha.asp. Updated March 19, 2018. Accessed July 5, 2018.

23. US Department of Veterans Affairs, Veterans Health Administration. Veterans Health Administration handbook 1601B.05: beneficiary travel. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2275. Published July 21, 2010. Accessed July 5, 2018.

24. Gellad WF. The Veterans Choice Act and dual health system use. J Gen Intern Med. 2016;31(2):153-154.

25. Kothari AN, Loy VM, Brownlee SA, et al. Adverse effect of post-discharge care fragmentation on outcomes after readmissions after liver transplantation. J Am Coll Surg. 2017;225(1):62-67.

26. Thorpe JM, Thorpe CT, Gellad WF, et al. Dual health care system use and high-risk prescribing in patients with dementia. Ann Int Med. 2017;166(3):157-163.

27. Tarlov E, Lee TA, Weichle TW, et al. Reduced overall and event-free survival among colon cancer patients using dual system care. Cancer Epidemiol Biomarkers Prev. 2012;21(12):2231-2241.

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