Mortality after kidney transplant twice as high with care through Medicare vs VA system
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The 5-year mortality rate for veterans who received care through Medicare after undergoing kidney transplantation was double that of those who received care through the Veterans Health Administration, study results showed.
“The results are very important in light of the fact that with the MISSION Act, many more veterans will now have the option of receiving their post-transplant care outside the VA in the private sector,” Steven D. Weisbord, MD, MSc, of the VA Pittsburgh Healthcare System, said in a related press release.
Writing that although it may seem “advantageous” to offer a variety of after transplant care options, the researchers contended an investigation into resulting patient outcomes was necessary.
With this in mind, Weisbord and colleagues assessed mortality rates in 6,206 kidney transplant recipients who were dually enrolled in Medicare and the VA. In addition to considering through which system care after transplant was received, the researchers also determined the source of transplantation and found 16% of the study population underwent the surgery at a VA hospital vs. 84% at a non-VA hospital using Medicare.
“We defined post-transplant care as transplant-related outpatient visits, immunosuppressive medication prescriptions and measurements of blood calcineurin inhibitor levels over 12 months after hospital discharge from transplant surgery,” the researchers wrote, categorizing source of care as VA only, Medicare only or both (ie, dual care).
Findings showed 12% of patients received care after transplant through VA only, 34% through Medicare only and 54% through dual care.
Researchers observed a “significantly higher” 5-year mortality rate for patients who received care after transplant through Medicare only (adjusted HR = 2.2) and those who received dual care (aHR = 1.5) compared with those who received care through VA only.
Weisbord and colleagues suggested that one reason mortality might be lower with VA care may be due to the integrated nature of the system.
“Several facets of the VA Healthcare System facilitate post-transplant care coordination that may be more challenging to achieve in the private sector,” the researchers wrote. “As a nationwide integrated health care system, the VA enables timely communication between providers at transplant centers and distant facilities. The capacity for telehealth visits in lieu of in-person examinations permits convenient and timely assessments by VA providers, and the universal electronic medical record allows providers to access test results and view prescribed medications anywhere within the VA. Such factors may contribute to more effective coordination of transplant care, which could translate into improved outcomes.”
In an accompanying editorial, Namrata Krishnan, MD, and Susan T. Crowley, MD, both of the Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine, suggested that although the reasons behind the mortality differences remain unclear (it could be due to “selection bias” and a healthier cohort using the VA system or higher quality care), the study is “notable for its large sample size, national scope and use of national data systems.”
Krishnan and Crowley also addressed gaps in health equity.
“Differential access to care, due to racism or geography, is an important determinant of kidney transplant outcomes,” they wrote. “Analyses of modifications to the VA’s national transplant system suggest the VA has mitigated racial disparities in veteran kidney transplant outcomes, including time to evaluation and receipt of transplantation. Examining site-of-care outcomes stratified by race and/or rurality would have illuminated the extent to which the mortality benefit associated with VA-only care extended equitably to all veterans managed within the VA-only cohort. Going forward, capture of the type and extent of telehealth used by veteran post-transplant care providers could quantify the ability of tele-technology to effectively surmount geographic barriers contributing to inequities in transplant care delivery.”
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