Click to Enlarge: Veteran (red) vs non-veteran (blue) parametric survival estimates with inset instantaneous hazard of death in the matched cohort. The solid lines represent estimates and dashed lines, 68% CIs. Symbols represent the Kaplan-Meier estimates for verification of model fit. Source: The Annals of Thoracic Surgery
CLEVELAND — For veterans with end-stage lung disease, the decision of where to pursue a lung transplant involves many practical and clinical considerations.
The VA provides transplant care through partnerships with select academic medical centers, including the University of Wisconsin in Madison and the University of Washington in Seattle. In the past, veterans were restricted to these or other VA-affiliated sites. Legislative changes—most notably the Veterans Choice Program in 2014 and the MISSION Act in 2018—have expanded options for eligible veterans to receive transplant services outside the VA system.
Although concerns have persisted about travel burdens and outcome quality, data on VA lung transplant performance remain limited. These concerns, coupled with the absence of comprehensive outcome data, have raised questions about how well VA-affiliated programs perform relative to non-VA centers.
To address this, researchers at the Cleveland Clinic and the University of Wisconsin, Madison analyzed the Organ Procurement and Transplantation Network (OPTN) lung transplant database, which included 31,302 adults waitlisted and 25,790 transplant recipients between January 2006 and March 2020. Veterans accounted for 416 waitlisted patients (1.3%) and 363 transplant recipients (1.4%), with most receiving care through VA programs.1
The study, published in The Annals of Thoracic Surgery, compared outcomes for veterans versus nonveterans and for veterans treated at VA-affiliated versus non-VA programs. According to the authors, “Survival from both the time of listing and transplant for all veterans and veterans treated through the VA lung transplant program is at least comparable to outcomes through non-VA programs,” indicating that VA programs deliver high-quality care.
“[T]he likelihood of undergoing lung transplantation and surviving on the waitlist was similar for veterans and non-veterans, as well as for veterans waitlisted through the VA program vs veterans waitlisted elsewhere,” the authors stated. One-year survival was 83% for veterans versus 80% for non-veterans. Among veterans, waitlist survival was similar between those treated at VA versus non-VA programs—80% versus 85% at 0.75 years.
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The study also highlighted regional differences. Areas including Madison, WI, and Seattle, where most VA transplants are performed, historically have lower waitlist mortality and better donor lung availability than many other regions. “Waitlist mortality is known to vary by region,” the researchers advised, “and the regions encompassing Madison, Wisconsin, and Seattle, Washington … historically have favorable donor lung availability and waitlist mortality compared with other regions nationally.” These regional factors might help explain why short-term post-transplant outcomes for veterans were comparable to those of nonveterans.
Short-term post-transplant outcomes were likewise comparable across groups. These findings are consistent with prior research in kidney and noncardiac surgery showing lower perioperative mortality and better outcomes in VA programs. The authors also noted that “VA measures of surgical quality and patient satisfaction [were] higher at VA programs than in adjacent non-VA programs.” While travel requirements can be inconvenient, the evidence indicated that the VA system supports strong outcomes even for highly complex procedures such as lung transplantation, they explained.
Long-term survival after transplant was similarly aligned. Five-year survival for veterans was 62% versus 58% for nonveterans treated outside the VA. Among veterans treated at VA programs, 5-year survival was 66% compared with 61% at non-VA programs. The researchers observed a nonstatistically significant trend favoring veterans after the first 2 to 3 years, suggesting that factors beyond the immediate perioperative period—such as VA prescription coverage or continuity of care—may contribute to this pattern. Veterans typically return home about 3 months post-transplant but continue follow-up with VA-affiliated transplant centers, ensuring ongoing management by experienced providers.
Overall, the findings underscored that the VA lung transplant program delivers care comparable to non-VA programs, even within a regionalized system that requires travel.
“Our findings suggest that the VA lung transplant program is functioning at a high level, with veterans likely receiving standard of care treatment,” the authors wrote. While community care under the MISSION Act may offer greater convenience, the study indicates it is unlikely to produce superior outcomes for most veterans.
For patients and caregivers weighing transplant options, these data provide reassurance. Veterans can make choices based on their individual medical needs, proximity to centers, and personal preferences, confident that the VA system maintains strong performance across the transplant continuum, the study concluded.
- Barron JO, Thuita L, Blackstone EH, Valapour M, et al. Lung Transplant Outcomes in the Veterans Health Administration. Ann Thorac Surg. 2025 Oct 10:S0003-4975(25)00958-0. doi: 10.1016/j.athoracsur.2025.09.014. Epub ahead of print. PMID: 41076000.
