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: 10181818
• 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/10181818
• 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VA已向退伍军人提供了挽救生命的器官移植数十年，但对 VA移植计划声称，其对退伍军人前往指定VA移植中心的要求 全国各地都减少了获得护理的机会。国会在2018年的《宣教法》明显通过 扩大了有资格购买社区移植和移植后护理的退伍军人人数。 我们最近调查了退伍军人在弗吉尼亚州双重招收的地方接受了肾脏移植 并接受了移植后护理以及移植护理部位与长期死亡率的关联。这 这项工作的发现表明，《任务法》可以实质上改变VA的模式和过程 移植和无意识导致移植后健康状况不利。 意义/影响：表征《任务法》对VA移植的影响以及 退伍军人接受移植护理的影响对于完善管理VA移植的政策至关重要 计划和资源分配，以支持将与移植相关的护理交付给退伍军人的终点 肾脏和/或肝病。我们的研究将提供有关《任务法》如何影响模式的新见解 以及移植护理的过程，以及退伍军人之间肾脏和肝移植的结果。 这项研究的发现将使退伍军人和VA提供者能够就来源做出基于证据的决策 优化长期同种异体移植功能和总体生存的移植护理。 创新：我们的研究将是第一个评估《任务法》对流程和结果的影响的研究 肾脏和肝移植护理以及唯一结合移植科学注册中数据的研究 收件人（SRTR）和VA公司数据仓库（CDW）来表征本立法的影响 关于退伍军人的移植护理和结果。 具体目标。我们的具体目的是：（1）描述VA和社区移植护理的临时模式（即 在批准的退伍军人中，在等待清单上的激活，接收移植和移植后管理） 执行《任务法》之前和之后的肾脏或肝移植； （2）确定患者和 与现场退伍军人相关的系统因素被列出并接受肾脏或肝移植 并获得移植后护理（VA与社区与双重）； （3）检查站点的关联：（a）等待 清单； （b）移植手术； （c）移植后护理具有关键结果（即等待清单上的时间，死亡 批准肾脏或肝脏的退伍军人中的等待名单，接收移植，同种异体失败和死亡率） 移植； （4）定性检查主要利益相关者（即退伍军人，弗吉尼亚州提供商，弗吉尼亚州运营 领导者）对退伍军人使用VA用于肾脏和肝移植护理的促进者和障碍的看法。 方法论：我们将将SRTR和CDW数据链接到构建VA的退伍军人队列 在UNOS等待名单上激活了肾脏和/或肝移植7/1/2010和6/30/2022之间。使用 这个队列，我们​​将表征VA和社区移植护理中的安全趋势，定量评估患者 与退伍军人接受移植并接受移植后护理相关的网站相关的系统因素， 并检查移植护理部位与关键移植相关结果的关联。我们也会 与退伍军人，VA提供商和VA运营负责人进行半结构化访谈以进行定性 评估他们对促进者的看法以及对退伍军人使用VA进行移植护理的障碍。 实施/下一步：我们的下一步将包括：（1）与运营领导者继续合作 VA的社区护理和国家手术办公室设计，部署和评估干预措施 这项研究得知，以改善退伍军人移植护理的过程和结果； （2）宽 将我们的发现传播给包括退伍军人，肾脏科医生，肝病学家和移植的主要利益相关者 外科医生向他们关于移植和移植后护理的最佳部位的决策提供了信息。