Patterns, Processes, and Outcomes of Kidney and Liver Transplantation in an Era of Enhanced Community Care for Veterans

加强退伍军人社区护理时代肾移植和肝移植的模式、过程和结果

• 批准号: 10394128
• 负责人: Steven Weisbord
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-05-01 至 2025-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10394128
• 关键词: Accountability; Administrator; Affect; Alcohol abuse; Allografting; Budgets; CCL4 gene; Caring; Cessation of life; Chronic; Code; Communities; Congresses; Data; Decision Making; Diabetes Mellitus; End stage renal failure; Enrollment; Failure; Health; Health Resources; Health Services Accessibility; Hepatitis; High Prevalence; Home; Hypertension; Institution; Insurance; Intervention; Interview; Kidney; Kidney Diseases; Kidney Transplantation; Lead; Life; Life Expectancy; Link; Liver diseases; Medical center; Medicare; Methodology; Office Surgery; Organ; Organ Transplantation; Outcome; Patients; Pattern; Perception; Policies; Process; Provider; Quality of life; Regression Analysis; Research; Resource Allocation; Risk; Sampling; Savings; Services; Site; Source; Statutes and Laws; Structure; System; Time; Transplant Recipients; Transplant Surgeon; Transplantation; Transplantation Surgery; Travel; United Network for Organ Sharing; Veterans; Veterans Health Administration; Waiting Lists; Work; administrative database; care outcomes; care systems; cohort; data warehouse; design; evidence base; experience; improved; innovation; insight; liver transplantation; medical specialties; military veteran; mortality; novel; operation; post-transplant; programs; transplant centers; transplant registry; trend

Background: While the VA has provided life-saving organ transplantation to Veterans for decades, critics of the VA Transplant Program claimed that its requirement for Veterans to travel to designated VA Transplant Centers across the nation reduced access to care. The passage of the MISSION Act by Congress in 2018 markedly expanded the number of Veterans eligible to pursue transplantation and post-transplant care in the community. We recently investigated where Veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care and the association of the site of transplant care with long-term mortality. The findings of this work suggest that the MISSION Act could substantially transform patterns and processes of VA transplant care and unintentionally lead to adverse health outcomes following transplantation. Significance/Impact: Characterizing the effects of the MISSION Act on VA transplantation and the factors that influence where Veterans receive transplant care is critical to refine policies governing the VA Transplant Program and allocation of resources to support the delivery of transplant-related care to Veterans with end-stage kidney and/or liver disease. Our study will provide novel insights into how the MISSION Act is affecting patterns and processes of transplant care, as well as outcomes of kidney and liver transplantation among Veterans. Findings from this study will enable Veterans and VA providers to make evidence-based decisions on the source of transplant care that optimizes long-term allograft function and overall survival. Innovation: Our study will be the first to assess the impact of the MISSION Act on processes and outcomes of kidney and liver transplant care and the only study to combine data from the Scientific Registry of Transplant Recipients (SRTR) and the VA Corporate Data Warehouse (CDW) to characterize the effect of this legislation on Veterans’ transplant care and outcomes. Specific Aims. Our specific aims are to: (1) describe temporal patterns of VA and community transplant care (i.e., activation on the wait list, receipt of transplant, and post-transplant management) among Veterans approved for kidney or liver transplantation before and after implementation of the MISSION Act; (2) identify patient and system factors associated with the site Veterans are wait listed for and undergo kidney or liver transplantation and receive post-transplant care (VA vs. community vs. dual); (3) examine the associations of site of: (a) wait listing; (b) transplant surgery; and (c) post-transplant care with key outcomes (i.e., time on the wait list, death on the wait list, receipt of transplant, allograft failure, and mortality) among Veterans approved for kidney or liver transplantation; and (4) qualitatively examine key stakeholders’ (i.e., Veterans, VA providers, VA operations leaders) perceptions of the facilitators of and barriers to Veterans’ use of VA for kidney and liver transplant care. Methodology: We will link SRTR and CDW data to construct a cohort of Veterans enrolled in VA who were activated on the UNOS wait list for kidney and/or liver transplantation between 7/1/2010 and 6/30/2022. Using this cohort, we will characterize secular trends in VA and community transplant care, quantitatively assess patient and system factors associated with the site that Veterans undergo transplant and receive post-transplant care, and examine the associations of site of transplant care with key transplant-related outcomes. We will also conduct semi-structured interviews with Veterans, VA providers, and VA operations leaders to qualitatively assess their perceptions of facilitators and barriers to Veterans’ use of VA for transplant care. Implementation/Next Steps: Our next steps will include: (1) continued partnership with operational leaders in VA’s Office of Community Care and National Surgery Office to design, deploy, and evaluate interventions informed by this research to improve the processes and outcomes of transplant care for Veterans; and (2) broad dissemination of our findings to key stakeholders including Veterans, nephrologists, hepatologists, and transplant surgeons to inform their decision-making regarding the optimal site of transplant and post-transplant care.

背景：虽然退伍军人管理局几十年来一直为退伍军人提供挽救生命的器官移植，但批评者 退伍军人管理局移植计划声称，其要求退伍军人前往指定的退伍军人管理局移植中心 2018 年国会通过的《使命法案》显着减少了全国范围内获得护理的机会。 扩大了有资格在社区进行移植和移植后护理的退伍军人数量。 我们最近调查了同时参加 VA 和 Medicare 的退伍军人接受肾移植的情况 并接受移植后护理以及移植护理部位与长期死亡率的关系。 这项工作的结果表明，《使命法案》可以大大改变 VA 的模式和流程 移植护理并无意中导致移植后不良的健康结果。 意义/影响：描述 MISSION 法案对 VA 移植的影响以及影响 VA 移植的因素 影响退伍军人接受移植护理的地点对于完善退伍军人管理局移植管理政策至关重要 支持向退伍军人提供终末期移植相关护理的计划和资源分配 我们的研究将为 MISSION 法案如何影响模式提供新的见解。 移植护理的过程，以及退伍军人肾脏和肝脏移植的结果。 这项研究的结果将使退伍军人和退伍军人管理局提供者能够对来源做出基于证据的决定 优化长期同种异体移植功能和总体生存率的移植护理。 创新：我们的研究将是第一个评估《使命法案》对过程和结果的影响的研究。 肾脏和肝脏移植护理以及唯一结合移植科学登记处数据的研究 接收者 (SRTR) 和 VA 企业数据仓库 (CDW) 描述该立法的影响 关于退伍军人的移植护理和结果。 具体目标。我们的具体目标是：(1) 描述 VA 和社区移植护理的时间模式（即， 批准接受移植的退伍军人中的等候名单激活、移植接收和移植后管理） 执行 MISSION 法案之前和之后进行肾脏或肝脏移植； (2) 识别患者并 与该地点相关的系统因素 退伍军人正在等待并接受肾脏或肝脏移植 并接受移植后护理（VA 与社区与双重）； (3) 检查以下部位的关联： (a) 等待 列出；(b) 移植手术；以及 (c) 具有关键结果的移植后护理（即等待名单上的时间、死亡时间） 批准接受肾脏或肝脏移植的退伍军人中的等候名单、移植接受情况、同种异体移植失败和死亡率） (4) 定性审查关键利益相关者（即退伍军人、退伍军人事务提供者、退伍军人事务部运营 领导人）对退伍军人使用 VA 进行肾脏和肝脏移植护理的促进因素和障碍的看法。 方法：我们将 SRTR 和 CDW 数据联系起来，构建一组参加 VA 的退伍军人，他们 2010 年 7 月 1 日至 2022 年 6 月 30 日期间在 UNOS 肾脏和/或肝脏移植等候名单上激活。 在这个队列中，我们将描述 VA 和社区移植护理的长期趋势，定量评估患者 以及与退伍军人接受移植和接受移植后护理的地点相关的系统因素， 并检查移植护理部位与关键移植相关结果的关联。 与退伍军人、退伍军人事务部提供者和退伍军人事务部运营负责人进行半结构化访谈，以定性 评估他们对退伍军人使用 VA 进行移植护理的促进因素和障碍的看法。 实施/后续步骤：我们的后续步骤将包括：(1) 与运营领导者继续合作 退伍军人管理局社区护理办公室和国家外科办公室负责设计、部署和评估干预措施 通过这项研究来改善退伍军人移植护理的过程和结果；(2) 广泛地 将我们的研究结果传播给主要利益相关者，包括退伍军人、肾脏病学家、肝病学家和移植专家 外科医生可以为他们关于最佳移植部位和移植后护理的决策提供信息。