Distance to VA Transplantation Centers Could Be a Factor

By Brenda L. Mooney

CLEVELAND—Veterans treated by the VA have lower rates of kidney transplantation when compared with patients who have Medicare or private insurance coverage, a new study found.

The research also detailed how VA patients had higher death rates while on the wait list for a kidney transplant, compared with other patients. The study was presented recently at the American Society of Nephrology’s Kidney Week 2017 meeting in New Orleans.1

A key factor, which has led to congressional legislation, is the significant distance veterans receiving care at the VA must travel for transplants compared to other patients.

Researchers from the Cleveland VAMC, the Cleveland Clinic and Case Western Reserve University noted that recent reports have demonstrated lower-than-expected kidney transplantation rates at the VA. They also pointed out that transplantation rates are easy to compare, because VAMCs are affiliated with non-VA academic centers in the same donor service areas (DSA).

Looking at all U.S. adult patients on the list for primary kidney transplants between 2004 to 2016 from Scientific Registry of Transplant Recipient (SRTR) data, the researchers compared 3,663 VA patients with 141,523 patients with private insurance, 25,245 with Medicaid and 132,026 with Medicare.

Results indicated that VA patients were 28% less likely to undergo transplantation than patients with private insurance nationally and 22% less likely than those with private insurance at their non-VA affiliates.

At the same time, VA patients were 14% less likely to undergo transplantation compared with those with Medicare nationally, although rates were similar compared with patients with Medicare in the non-VA centers. Little difference was detected between transplantation rates among those with VA healthcare and Medicaid insurance.

Higher Death Rates

In explaining higher death rates for VA patients while on the waiting list, researchers suggested distance from transplantation facilities was a factor. VA patients lived an average of 282 miles from the transplant centers, compared with an average of 23 miles for non-VA patients, the study emphasized.

“VA patients appear to have greater barriers to transplantation leading to lower rates of transplant and greater waitlist mortality compared with privately insured patients listed in local competing centers,” explained lead author Joshua Augustine, MD, of the Cleveland Clinic. “The much greater distance from transplant centers may contribute to lower transplant rates in veterans, and other factors related to organ acceptance or center practices may also contribute to differences.”

Additional analyses are required to determine the primary factors leading to discrepancies in transplant rates between VA and non-VA patients. “Ultimately, greater acceptance/coverage of VA insurance in local non-VA transplant centers may improve transplant rates for Veterans in the United States,” Augustine added.

The issue has not gone unnoticed. In October, the House Veterans’ Affairs Committee held a hearing on legislation to improve veterans’ access to organ transplants.

The Veterans Increased Choice for Transplanted Organs and Recovery (VICTOR) Act of 2017 allows veterans who live more than 100 miles from one of the nation’s 14 VA transplant centers to seek care at a federally certified, non-VA facility that covers Medicare patients.

“The VICTOR Act is a common sense solution to a problem that is quite literally hurting our veterans and preventing them from receiving timely organ transplants,” explained the bill’s sponsor, Rep. Neal Dunn (R-FL). “A veteran in Ocala would have to travel more than 600 miles to receive a new liver, despite having seven federally certified transplant centers in Florida. Many veterans are forced to sit on waiting lists for organs they may never receive. This needs to change.”

Currently, the VA only covers transplants performed at a VA Transplant Center, and waiting times for a transplant at the VA centers are on average 32 percent longer than those at non-VA facilities, said Dunn, who is a surgeon who served 11 years in the Army and is on the House Veterans’ Affairs Committee.

For example, the nearest VA facility to his district in Florida that performs heart, kidney or liver transplants is in Nashville, TN. The VICTOR Act is co-sponsored by 25 members of the House.

Background information in the recent study pointed out that veterans don’t incur any cost for kidney transplantation within the VA system, but transplant availability has historically been limited to only four VA centers nationwide.

The study found that, compared to privately-insured patients, veterans treated by the VA for advanced kidney disease were older and mostly male, with more black patients, and those with diabetes and vascular disease.

VA patients had more than 10 times the difference in distance from a transplant center. The unadjusted cumulative incidence of wait-list mortality at two years was 7.0 in VA patients, 5.8 in privately insured patients nationally and 4.6 in privately insured patients treated at non-VA affiliate centers in the same area.

“VA patients had a lower rate of transplantation and greater waitlist mortality compared to PI patients both nationally and within four paired NVA academic centers that shared DSAs,” study authors concluded. “The reasons for this discrepancy require further study, but may include differences in patient availability and organ acceptance between VA and non-VA centers.”

  1. Augustine, JJ, Arrigain, S, Balabhadrapatruni, Krishna P, Desai, N, Schold, JD. Significantly Lower Rates of Transplantation and Increased Wait List Mortality among Kidney Transplant Candidates with VA Insurance. Present at ASN Kidney Week 2017. New Orleans, LA. Oct. 31-Nov.5.