Abstract
The VHA provides timely solid organ transplant care and services with outcomes comparable to that of nationally reported estimates.
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
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
RESULTS
For FY 2014 to FY 2016, the referral cohort identified 6,009 veteran referrals to a VATC for solid organ transplant of which 3,500 underwent an evaluation, and 2,137 were wait-listed for solid organ transplant with UNOS (Table 1). Overall, 9.6% of referrals, 13.8% of evaluations, and 15.8% of those waitlisted were from VA referring centers less than 100 miles of the VATC. Alternatively, 37.2% of referrals, 33.3% of evaluations, and 30.4% of waitlistings were assigned a referral distance of greater than 500 miles. This suggests that a referral distance less than 100 miles provides a small but measurable positive benefit, whereas a referral distance of greater than 500 miles impacts the veteran negatively. Further analysis of the 577 referrals from less than 100 miles determined that 456 (79.0%) originate from the VATC as a direct referral. Of the 338 wait-listed referrals less than 100 miles, only 53 (15.7%) were from a separate VA medical facility, indicating a preference for VATCs to process direct referrals in a manner that promotes waitlisting.
TABLE 1.
Referrals, Evaluations, and Veterans Waitlisted by Distance, Fiscal Years 2014 to 2016
| Distance, miles | Referrals, No. (%) | Evaluations, No. (%) | Listings, No. (%) |
|---|---|---|---|
| Heart | |||
| < 100 | 51 (10.8) | 43 (14.1) | 22 (16.2) |
| 100–300 | 144 (30.6) | 84 (27.5) | 39 (28.7) |
| 301–500 | 106 (22.5) | 73 (23.9) | 27 (19.9) |
| > 500 | 170 (36.1) | 106 (34.6) | 48 (35.3) |
| All distances | 471 | 306 | 136 |
|
| |||
| Kidney | |||
| < 100 | 276 (8.4) | 230 (11.8) | 164 (12.8) |
| 100–300 | 964 (29.4) | 592 (30.3) | 390 (30.5) |
| 301–500 | 869 (26.5) | 456 (23.3) | 313 (24.5) |
| > 500 | 1,167 (35.6) | 675 (34.6) | 413 (32.3) |
| All distances | 3,276 | 1,953 | 1,280 |
|
| |||
| Liver | |||
| < 100 | 235 (12.6) | 203 (18.6) | 146 (22.0) |
| 100–300 | 642 (34.4) | 386 (35.3) | 237 (35.7) |
| 301–500 | 371 (19.9) | 212 (19.4) | 127 (19.1) |
| > 500 | 619 (33.2) | 292 (26.7) | 154 (23.2) |
| All distances | 1,867 | 1,093 | 664 |
|
| |||
| Lung | |||
| < 100 | 15 (3.8) | 7 (4.7) | 6 (10.5) |
| 100–300 | 38 (9.6) | 20 (13.5) | 4 (7.0) |
| 301–500 | 64 (16.2) | 29 (19.6) | 12 (21.1) |
| > 500 | 278 (70.4) | 92 (62.2) | 35 (61.4) |
| All distances | 395 | 148 | 57 |
|
| |||
| All organs | |||
| < 100 | 577 (9.6) | 483 (13.8) | 338 (15.8) |
| 100–300 | 1,788 (29.8) | 1,082 (30.9) | 670 (31.4) |
| 301–500 | 1,410 (23.5) | 770 (22.0) | 479 (22.4) |
| > 500 | 2,234 (37.2) | 1,165 (33.3) | 650 (30.4) |
| All distances | 6,009 | 3,500 | 2,137 |
For the study period, 6,009 referrals resulted in 188 emergency initial review decisions and 3,551 stable initial review decisions with an eligible declaration (Table 2). The median time for emergency referral initial review decision was 5 hours, with an interquartile range (IQR) of 2 to 22 hours. Fourteen emergency initial review decisions (5.2%) were submitted by the VATC beyond the 48 hours mandated by policy. The median time for stable referral initial review decision was 3 business days (IQR 2–5 d) with 650 stable initial review decisions (12.5%) submitted beyond the 5 business days mandated by policy. In FY 2016, all 90 emergency referrals received an initial review decision within 48 hours, and all but 169 (8.6%) of stable referrals received an initial review decision within 5 business days, representing an improvement over FY 2014 and FY 2015.
TABLE 2.
Timeliness of Referral, Initial Decision Review, Evaluation, and Waitlisting
| Referrals | Emergency Reviews | Stable Reviews | Evaluations | Listings | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Distances, miles | Submitted | Closed After Referral | Discontinued | Total Decisions | Eligible Decisions | Closed After Decision | > 48 h, No. (%) | Median, h | IQR, h | Total Decisions | Eligible Decisions | Closed After Decision | > 5 Bus. Days, No. (%) | Median Bus. Days (IQR) | Completed | Closed After Evaluation | Telehealth, No. (%) | > 30 Days, No. (%) | Median Days (IQR) | Completed | Median Days (IQR) |
| FY 2014 | |||||||||||||||||||||
| < 100 | 173 | - | 7 | 9 | 9 | 1 | - | 0 | 0–2 | 157 | 139 | 4 | 15 (9.6) | 2 (1–3) | 143 | 31 | 2 (1.4) | 31 (21.7) | 22 (11–29) | 106 | 69 (31–119) |
| 100–300 | 538 | - | 81 | 25 | 18 | 1 | 2 (8.0) | 1 | 1–17 | 432 | 298 | 16 | 77 (17.8) | 3 (2–5) | 299 | 88 | 50 (16.7) | 131 (43.8) | 29 (22–44) | 197 | 91 (45–159) |
| 301–500 | 406 | 1 | 47 | 22 | 18 | 2 | 1 (4.5) | 5 | 2–22 | 336 | 225 | 10 | 71 (21.1) | 4 (2–5) | 231 | 70 | 30 (13.0) | 96 (41.6) | 29 (24–44) | 152 | 98 (57–220) |
| > 500 | 729 | 2 | 77 | 26 | 21 | 4 | 3 (11.5) | 16 | 2–39 | 624 | 379 | 23 | 91 (14.6) | 3 (2–5) | 372 | 138 | 57 (15.3) | 220 (59.1) | 35 (26–54) | 209 | 98 (61–220) |
| All distances | 1,846 | 3 | 212 | 82 | 66 | 8 | 6 (7.3) | 3 | 1–20 | 1,549 | 1,041 | 53 | 254 (16.4) | 3 (2–5) | 1,045 | 327 | 139 (13.3) | 478 (45.7) | 30 (22–48) | 664 | 90 (49–182) |
|
| |||||||||||||||||||||
| FY 2015 | |||||||||||||||||||||
| < 100 | 185 | 1 | 4 | 13 | 11 | - | - | 2 | 1–6 | 167 | 151 | 9 | 11 (6.6) | 1 (1–3) | 153 | 30 | 0 (0.0) | 26 (17.0) | 20 (9–28) | 112 | 45 (24–91) |
| 100–300 | 545 | 1 | 40 | 25 | 17 | - | 2 (8.0) | 4 | 1–23 | 479 | 338 | 18 | 72 (15.0) | 3 (2–5) | 337 | 98 | 72 (21.4) | 71 (21.1) | 26 (20–29) | 209 | 84 (37–154) |
| 301–500 | 466 | 2 | 33 | 23 | 16 | 3 | 1 (4.3) | 3 | 1–24 | 408 | 262 | 22 | 82 (20.1) | 3 (2–5) | 253 | 70 | 51 (20.2) | 69 (27.3) | 27 (22–32) | 164 | 89 (63–190) |
| > 500 | 734 | 2 | 69 | 34 | 18 | 4 | 5 (14.7) | 17 | 3–22 | 629 | 396 | 19 | 62 (9.9) | 3 (2–4) | 391 | 142 | 72 (18.4) | 131 (33.5) | 28 (22–36) | 209 | 78 (47–144) |
| All distances | 1,930 | 6 | 146 | 95 | 62 | 7 | 8 (8.4) | 4 | 1–22 | 1,683 | 1,147 | 68 | 227 (13.5) | 3 (2–4) | 1,134 | 340 | 195 (17.2) | 297 (26.2) | 26 (20–32) | 694 | 76 (39–152) |
|
| |||||||||||||||||||||
| FY 2016 | |||||||||||||||||||||
| < 100 | 219 | 10 | 15 | 13 | 1 | - | 3 | 2–7 | 194 | 180 | 5 | 2 (1.0) | 1 (1–2) | 187 | 37 | 4 (2.1) | 23 (12.3) | 20 (10–27) | 120 | 62 (32–109) | |
| 100–300 | 705 | 4 | 51 | 25 | 15 | - | - | 17 | 4–27 | 625 | 453 | 22 | 67 (10.7) | 3 (2–5) | 446 | 117 | 87 (19.5) | 58 (13.0) | 26 (20–28) | 264 | 73 (41–120) |
| 301–500 | 538 | 3 | 44 | 16 | 11 | 2 | - | 13 | 3–23 | 475 | 305 | 28 | 42 (8.8) | 2 (2–5) | 286 | 78 | 59 (20.6) | 37 (12.9) | 26 (21–29) | 163 | 78 (51–139) |
| > 500 | 771 | 2 | 63 | 34 | 21 | 9 | - | 4 | 3–8 | 672 | 425 | 35 | 58 (8.6) | 3 (2–4) | 402 | 112 | 71 (17.7) | 55 (13.7) | 26 (21–28) | 232 | 68 (41–137) |
| All distances | 2,233 | 9 | 168 | 90 | 60 | 12 | - | 6 | 3–23 | 1,966 | 1,363 | 90 | 169 (8.6) | 3 (2–4) | 1,321 | 344 | 221 (16.7) | 173 (13.1) | 25 (20–28) | 779 | 70 (41–127) |
|
| |||||||||||||||||||||
| All years | |||||||||||||||||||||
| < 100 | 577 | 1 | 21 | 37 | 33 | 2 | - | 2 | 1–6 | 518 | 470 | 18 | 28 (5.4) | 1 (1–3) | 483 | 98 | 6 (1.2) | 80 (16.6) | 21 (10–28) | 338 | 57 (31–106) |
| 100–300 | 1,788 | 5 | 172 | 75 | 50 | 1 | 4 (5.3) | 5 | 1–24 | 1,536 | 1,089 | 56 | 216 (14.1) | 3 (2–5) | 1,082 | 303 | 209 (19.3) | 260 (24.0) | 26 (20–30) | 670 | 78 (42–143) |
| 301–500 | 1,410 | 6 | 124 | 61 | 45 | 7 | 2 (3.3) | 6 | 2–23 | 1,219 | 792 | 60 | 195 (16.0) | 3 (2–5) | 770 | 218 | 140 (18.2) | 202 (26.2) | 27 ( 22–32) | 479 | 86 (56–173) |
| > 500 | 2,234 | 6 | 209 | 94 | 60 | 17 | 8 (8.5) | 5 | 3–21 | 1,925 | 1,200 | 77 | 211 (11.0) | 3 (2–4) | 1,165 | 392 | 200 (17.2) | 406 (34.8) | 28 ( 22–39) | 650 | 82 (47–161) |
| All distances | 6,009 | 18 | 526 | 267 | 188 | 27 | 14 (5.2) | 5 | 2–22 | 5,198 | 3,551 | 211 | 650 (12.5) | 3 (2–5) | 3,500 | 1,011 | 555 (15.9) | 948 (27.1) | 27 (21–32) | 2,137 | 78 (43–148) |
Abbreviations: bus., business; FY, fiscal year; IQR, interquartile range.
Three thousand five hundred evaluations were performed in a median time of 27 calendar days (IQR 21–32 d) with 948 (27.1%) performed beyond the policy mandated 30 calendar days. Telehealth was used for 555 evaluations (15.9%), primarily for referrals located greater than 100 miles from the VATC. In FY 2016, 13.1% of the 1,321 completed evaluations were performed beyond 30 calendar days, representing an improvement from prior years; 45.7% beyond 30 calendar days in FY 2014 and 26.2% beyond 30 days in FY 2015.
Of the 6,009 referrals submitted in FY 2014 to FY 2016, 2,137 were wait-listed with UNOS. The median time from referral to waitlisting was 78 calendar days (IQR 43–148 d) for the entire study period, decreasing from 90 calendar days in FY 2014 to 70 calendar days in FY 2016.
For all organs and most organ types, the time from referral to initial review decision, evaluation, and waitlisting was statistically less (P < .005) for referrals received from VA medical facilities located less than 100 miles compared with referrals received from VA medical facilities at least 100 miles from the VATC. No statistical difference was found for emergency initial review decision for heart (P = .72) and lung (P = .14), time to evaluation for lung (P = .14), and time to waitlisting for heart (P = .95).
The waitlist cohort data are shown in Table 3. For FY 2014 to FY 2016, 2,265 veterans were waitlisted with UNOS of which 144 (6.4%) died on the waitlist and 731 (32.3%) underwent transplantation. The waitlist mortality rate varied by organ type: heart 4.5%, kidney 4.5%, liver 10.6%, and lung 6.6%. The transplant rate for this cohort varied by organ type: heart 64.4%, kidney 17.2%, liver 52.9%, and lung 78.7%. The median time from initial waitlisting to transplantation was 157 days for all organs and varied by organ type: heart 162 days, kidney 255 days, liver 113 days, and lung 110 days.
TABLE 3.
Outcomes of Veterans Waitlisted With UNOS for Fiscal Years 2014 to 2016
| Mortality on UNOS List | Transplants | Removed From VATC Listing | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Initial UNOS Listings | Count | Time From Listing to Mortality, d | Count | Time From Listing to Transplant, d | Overall | Failure to Meet Criteria | Patient Choice | Mortality After TRACER Closure and Prior to 3/31/17 | Mortality for Patients Not Transplanted at a VATC | On the UNOS List at 3/31/17 | |||
| Distances, miles | No. (%) | No. (%) | Median | IQR | No. (%) | Median | IQR | No. (%) | No. | No. | No. (%) | No. (%) | No. (%) |
| Heart | |||||||||||||
| < 100 | 20 (15.2) | 1 (5.0) | 142 | 142–142 | 12 (60.0) | 94 | 69–219 | - | - | - | - | 1 (5.0) | 7 (35.0) |
| 100 to 300 | 43 (32.6) | 4 (9.3) | 259 | 119–492 | 25 (58.1) | 133 | 37–236 | 5 (11.6) | 3 | 2 | 2 (40.0) | 6 (14.0) | 9 (20.9) |
| 301 to 500 | 26 (19.7) | 1 (3.8) | 232 | 232–232 | 15 (57.7) | 190 | 77–348 | 0 | 0 | 0 | - | 1 (3.8) | 10 (38.5) |
| > 500 | 43 (32.6) | 0 | - | - | 33 (76.7) | 206 | 47–340 | 4 (9.3) | 1 | 3 | - | 0 (0.0) | 6 (14.0) |
| All distances | 132 | 6 (4.5) | 215 | 142–320 | 85 (64.4) | 162 | 49–311 | 9 (6.8) | 4 | 5 | 2 (22.2) | 8 (6.1) | 32 (24.2) |
|
| |||||||||||||
| Kidney | |||||||||||||
| < 100 | 152 (10.9) | 10 (6.6) | 339 | 214–560 | 21 (13.8) | 397 | 121–780 | 13 (8.6) | 12 | 1 | 1 (7.7) | 11 (7.2) | 108 (71.1) |
| 100 to 300 | 409 (29.4) | 18 (4.4) | 199 | 103–551 | 62 (15.2) | 245 | 133–549 | 59 (14.4) | 27 | 32 | 9 (15.3) | 27 (6.6) | 270 (66.0) |
| 301 to 500 | 346 (24.8) | 16 (4.6) | 428 | 284–606 | 54 (15.6) | 246 | 84–663 | 59 (17.1) | 29 | 30 | 4 (6.8) | 20 (5.8) | 217 (62.7) |
| > 500 | 486 (34.9) | 18 (3.7) | 383 | 108–590 | 102 (21.0) | 256 | 115–457 | 85 (17.5) | 47 | 38 | 6 (7.1) | 24 (4.9) | 281 (57.8) |
| All distances | 1,393 | 62 (4.5) | 342 | 142–560 | 239 (17.2) | 255 | 113–571 | 216 (15.5) | 115 | 101 | 20 (9.3) | 82 (5.9) | 876 (62.9) |
|
| |||||||||||||
| Liver | |||||||||||||
| < 100 | 146 (21.5) | 14 (9.6) | 44 | 21–326 | 83 (56.8) | 123 | 29–353 | 25 (17.1) | 22 | 3 | 11 (44.0) | 25 (17.1) | 24 (16.4) |
| 100 to 300 | 246 (36.2) | 28 (11.4) | 123 | 56–243 | 139 (56.5) | 126 | 22–245 | 36 (14.6) | 28 | 8 | 19 (52.8) | 47 (19.1) | 43 (17.5) |
| 301 to 500 | 125 (18.4) | 15 (12.0) | 208 | 96–322 | 59 (47.2) | 129 | 27–279 | 21 (16.8) | 16 | 5 | 8 (38.1) | 23 (18.4) | 30 (24.0) |
| > 500 | 162 (23.9) | 15 (9.3) | 323 | 36–517 | 78 (48.1) | 80 | 15–200 | 27 (16.7) | 23 | 4 | 19 (70.4) | 34 (21.0) | 42 (25.9) |
| All distances | 679 | 72 (10.6) | 139 | 43–323 | 359 (52.9) | 113 | 24–263 | 109 (16.1) | 89 | 20 | 57 (52.3) | 129 (19.0) | 139 (20.5) |
|
| |||||||||||||
| Lung | |||||||||||||
| < 100 | 8 (13.1) | 0 | - | - | 7 (87.5) | 87 | 20–170 | 1 (12.5) | 1 | 0 | 1 (100.0) | 1 (12.5) | - |
| 100 to 300 | 6 (9.8) | 1 (16.7) | 128 | 128–128 | 4 (66.7) | 128 | 71–168 | 1 (16.7) | 1 | 0 | 1 (100.0) | 2 (33.3) | - |
| 301 to 500 | 14 (23.0) | 1 (7.1) | 15 | 15–15 | 12 (85.7) | 105 | 10–204 | 1 (7.1) | 1 | 0 | - | 1 (7.1) | - |
| > 500 | 33 (54.1) | 2 (6.1) | 122 | 22–221 | 25 (75.8) | 110 | 45–237 | 2 (6.1) | 1 | 1 | 1 (50.0) | 3 (9.1) | 4 (12.1) |
| All distances | 61 | 4 (6.6) | 75 | 19–175 | 48 (78.7) | 110 | 37–204 | 5 (8.2) | 4 | 1 | 3 (60.0) | 7 (11.5) | 4 (6.6) |
|
| |||||||||||||
| All organs | |||||||||||||
| < 100 | 326 (14.4) | 25 (7.7) | 183 | 37–396 | 123 (37.7) | 165 | 38–397 | 39 (12.0) | 35 | 4 | 13 (33.3) | 38 (11.7) | 139 (42.6) |
| 100 to 300 | 704 (31.1) | 51 (7.2) | 142 | 77–298 | 230 (32.7) | 150 | 38–291 | 101 (14.3) | 59 | 42 | 31 (30.7) | 82 (11.6) | 322 (45.7) |
| 301 to 500 | 511 (22.6) | 33 (6.5) | 294 | 118–445 | 140 (27.4) | 178 | 42–401 | 81 (15.9) | 46 | 35 | 12 (14.8) | 45 (8.8) | 257 (50.3) |
| > 500 | 724 (32.0) | 35 (4.8) | 326 | 83–555 | 238 (32.9) | 154 | 49–308 | 118 (16.3) | 72 | 46 | 26 (22.0) | 61 (8.4) | 333 (46.0) |
| All distances | 2,265 | 144 (6.4) | 227 | 81–407 | 731 (32.3) | 157 | 42–333 | 339 (15.0) | 212 | 127 | 82 (24.2) | 226 (10.0) | 1,051 (46.4) |
Abbreviations: IQR, interquartile range; UNOS, United Network for Organ Sharing, VATC, Veterans Affairs Transplant Center.
TRACER identified that 339 (15.0%) of the waitlist cohort were removed from the UNOS waitlist of which 212 (62.5%) were removed for failure to meet clinical criteria for transplantation, and 127 (37.5%) were removed for patient choice. Overall, 226 (10.0%) veterans died during the study period without receiving a transplant. Organ-specific mortality rates for veterans waitlisted but not transplanted at a VATC are as follows: heart 6.1%, kidney 5.9%, liver 19.0%, and lung 11.5%. As of March 31, 2017, 1,051 veterans were waitlisted with UNOS of which 876 (83.3%) were waitlisted for a kidney transplant.
The rate of mortality on the UNOS wait-list, the percentage of veterans transplanted, the time from waitlisting to transplantation, and the percentage of patients waitlisted at the end of the study period were not statistically different for referrals less than 100 miles compared with referrals at least 100 miles for all organs or kidney and liver separately (P ≤ .05). The relatively small numbers of veterans waitlisted for heart and lung transplants and nominal mortality events precluded making statements regarding significance for waitlist mortality.
The transplant cohort comprised 947 veterans receiving a solid organ transplant, including 102 (10.8%) heart, 411 (43.4%) kidney, 383 (40.4%) liver, and 51 (5.4%) lung transplants (Table 4). The median time from referral to evaluation was 34 days (IQR 21–85 d), referral to waitlisting was 107 days (IQR 48–218 d), and referral to transplant was 444 days (IQR 190–994d). This cohort includes the 731 transplants identified in the waitlist cohort plus 216 transplants performed on referrals waitlisted before October 1, 2013. These 216 transplants (17 heart, 172 kidney, 24 liver, and 3 lung) negatively influenced the timeliness of evaluations, waitlisting, and transplantation most notably with kidney transplantation. Time from referral to transplant was evaluated separately for all organs and each organ type separately, finding no statistical difference for referrals from VA medical facilities less than 100 miles from a VATC compared with referrals at least 100 miles in any category (P > .05).
TABLE 4.
Timeliness of Referral Evaluation, Waitlisting, and Transplantation for Transplants Performed in Fiscal Years 2014 to 2016
| Distances, miles | Transplants Performed, No. (%) | Median Referral to Evaluation, d (IQR) | Median Referral to Listing, d (IQR) | Median Referral to Transplant, d (IQR) |
|---|---|---|---|---|
| Heart | ||||
| < 100 | 18 (17.6) | 2 (1–6) | 4 (1–9) | 327 (97–675) |
| 100 to 300 | 31 (30.4) | 19 (5–33) | 63 (20–199) | 352 (185–748) |
| 301 to 500 | 18 (17.6) | 20 (7–28) | 60 (22–213) | 405 (214–784) |
| > 500 | 35 (34.3) | 20 (6–27) | 50 (25–118) | 263 (106–515) |
| All distances | 102 | 16 (4–28) | 50 (16–142) | 301 (151–675) |
|
| ||||
| Kidney | ||||
| < 100 | 44 (10.7) | 41 (19–70) | 77 (45–165) | 1,113 (613–1,646) |
| 100 to 300 | 109 (26.5) | 85 (36–144) | 169 (107–304) | 915 (475–1,536) |
| 301 to 500 | 86 (20.9) | 103 (46–206) | 200 (101–390) | 947 (479–1,511) |
| > 500 | 172 (41.8) | 85 (45–158) | 177 (107–315) | 839 (420–1,414) |
| All distances | 411 | 81 (36–150) | 169 (96–308) | 914 (460–1,506) |
|
| ||||
| Liver | ||||
| < 100 | 82 (21.4) | 19 (5–35) | 41 (15–86) | 276 (72–550) |
| 100 to 300 | 144 (37.6) | 25 (12–34) | 63 (31–126) | 225 (99–394) |
| 301 to 500 | 62 (16.2) | 26 (15–33) | 85 (36–142) | 288 (120–547) |
| > 500 | 95 (24.8) | 34 (23–54) | 79 (51–165) | 240 (89–522) |
| All distances | 383 | 26 (14–39) | 70 (32–131) | 236 (91–500) |
|
| ||||
| Lung | ||||
| < 100 | 9 (17.6) | 5 (2–24) | 26 (7–155) | 229 (90–351) |
| 100 to 300 | 4 (7.8) | 62 (47–93) | 317 (85–604) | 426 (155–743) |
| 301 to 500 | 15 (29.4) | 39 (29–54) | 87 (68–213) | 279 (170–585) |
| > 500 | 23 (45.1) | 30 (26–42) | 117 (85–155) | 205 (139–444) |
| All distances | 51 | 31 (23–49) | 99 (68–203) | 246 (139–466) |
|
| ||||
| All organs | ||||
| < 100 | 153 (16.2) | 21 (5–41) | 46 (15–105) | 410 (99–851) |
| 100 to 300 | 288 (30.4) | 32 (20–81) | 105 (43–204) | 380 (185–956) |
| 301 to 500 | 181 (19.1) | 36 (24–114) | 138 (69–259) | 523 (239–1,109) |
| > 500 | 325 (34.3) | 48 (27–104) | 126 (71–237) | 485 (205–1,045) |
| All distances | 947 | 34 (21–85) | 107 (48–218) | 444 (190–994) |
Abbreviation: IQR, interquartile range.
The transplant 30-day, 180-day, and 1-year survival rates are shown in Table 5. The 1-year survival rates for the VATP are as follows: heart 95.1%, kidney 97.4%, liver 91.7%, and lung 89.7%. These survival rates are on par or better than SRTR comparative estimates. Transplant survival rates were evaluated for each organ type separately, finding no statistical difference for referrals from VA medical facilities less than 100 miles compared with referrals at least 100 miles from a VATC in any category (P > .05).
TABLE 5.
Kaplan-Meier Survival Estimates by Distance Group for Transplants Performed in FY 2014 to FY 2016 Compared With SRTR Survival Estimates
| Distances, miles | Transplants Performed, No. (%) | Mortalities, No. | Kaplan-Meier Survival Estimate, % | ||||
|---|---|---|---|---|---|---|---|
| 30 Days | 180 Day | 1 Year | 30 Days | 180 Days | 1 Year | ||
| Heart | |||||||
| < 100 | 18 (17.6) | 0 | 0 | 1 | 100 | 100 | 94.4 |
| 100 to 300 | 31 (30.4) | 1 | 2 | 2 | 96.8 | 93.5 | 93.5 |
| 301 to 500 | 18 (17.6) | 0 | 0 | 0 | 100 | 100 | - |
| > 500 | 35 (34.3) | 0 | 2 | 2 | 100 | 94.3 | 94.3 |
| All distances | 102 | 1 | 4 | 5 | 99.0 | 96.1 | 95.1 |
| SRTR National | - | - | - | 96.1 | - | 90.5 | |
|
| |||||||
| Kidney | |||||||
| < 100 | 44 (10.7) | 0 | 0 | 0 | 100 | 100 | - |
| 100 to 300 | 109 (26.5) | 0 | 2 | 3 | 100 | 98.2 | 97.0 |
| 301 to 500 | 86 (20.9) | 0 | 1 | 3 | 100 | 98.8 | 96.4 |
| > 500 | 172 (41.8) | 1 | 2 | 4 | 99.4 | 98.8 | 97.6 |
| All distances | 411 | 1 | 5 | 10 | 99.8 | 98.8 | 97.4 |
| SRTR National | - | - | - | 99.5 | - | 97.3 | |
|
| |||||||
| Liver | |||||||
| < 100 | 82 (21.4) | 1 | 3 | 5 | 98.8 | 96.3 | 93.9 |
| 100 to 300 | 144 (37.6) | 4 | 8 | 13 | 97.2 | 94.4 | 90.5 |
| 301 to 500 | 62 (16.2) | 2 | 7 | 8 | 96.8 | 88.7 | 87.0 |
| > 500 | 95 (24.8) | 1 | 3 | 5 | 98.9 | 96.8 | 94.5 |
| All distances | 383 | 8 | 21 | 31 | 97.9 | 94.5 | 91.7 |
| SRTR National | - | - | - | 97.3 | - | 91.6 | |
|
| |||||||
| Lung | |||||||
| < 100 | 9 (17.6) | 0 | 0 | 0 | 100 | 100 | 100 |
| 100 to 300 | 4 (7.8) | 0 | 0 | 0 | 100 | 100 | 100 |
| 301 to 500 | 15 (29.4) | 0 | 2 | 3 | 100 | 86.7 | 78.0 |
| > 500 | 23 (45.1) | 0 | 2 | 2 | 100 | 91.3 | 91.3 |
| All distances | 51 | 0 | 4 | 5 | 100 | 92.2 | 89.7 |
| SRTR National | - | - | - | 97.2 | - | 87.6 | |
Abbreviations: FY, fiscal year; SRTR, Scientific Registry for Transplant Recipients.
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 wait-listing 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 post-transplant 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 wait-list 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.
Limitations
The retrospective design and limited study period represent limitations. Specifically, survival outcomes for veterans transplanted were limited to 1 year and do not rule out the possibility that distance to a VATC will impact survival rates at 3 and 5 years posttransplant.
CONCLUSION
A referral distance of less than 100 miles from the VATC most often represents a direct referral and is a factor in timeliness of transplant initial review decision, evaluation, and placement of the veteran on the UNOS waitlist. Distance between the referring VA medical facility and the VATC, including distances of greater than 500 miles, was not found to impact the rate of mortality on the UNOS waitlist, time to transplantation, or post-transplant survival. Overall, the VHA provides timely solid organ transplant care and services with outcomes comparable to that of nationally reported SRTR estimates. Future studies should examine the timeliness of services, outcomes, and costs associated with those veterans authorized by the VHA for non-VA community care and those veterans who independently elect to receive transplant care and services by a non-VA transplant center and return to the VHA for dual care following transplantation.
Footnotes
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
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