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.
Dr. Gunnar is National Director of Surgery, Dr. Bronson is Chief Biostatistician, and Dr. Cupples is Director of Clinical Services, all at the National Surgery Office, Veterans Health Administration in Washington, DC. Dr. Gunnar also is a Clinical Professor of Surgery at George Washington University in Washington, DC. Correspondence: Dr. Gunnar (william.gunnar@va.gov)
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 waitlisted 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.
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.
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 waitlisted 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.
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 waitlist, 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 190-994 d). This cohort includes the 731 trans-plants 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).
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).
