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Original ArticlesTransplantation
Open Access

Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare

Winn Cashion, Walid F. Gellad, Florentina E. Sileanu, Maria K. Mor, Michael J. Fine, Jennifer Hale, Daniel E. Hall, Shari Rogal, Galen Switzer, Mohan Ramkumar, Virginia Wang, Douglas A. Bronson, Mark Wilson, William Gunnar and Steven D. Weisbord
CJASN March 2021, 16 (3) 437-445; DOI: https://doi.org/10.2215/CJN.10020620
Winn Cashion
1Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Walid F. Gellad
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
3Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Florentina E. Sileanu
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Maria K. Mor
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
4Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Michael J. Fine
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
3Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Jennifer Hale
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Daniel E. Hall
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
5Departments of Surgery, Anesthesia and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Shari Rogal
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Galen Switzer
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
3Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Mohan Ramkumar
1Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
6Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Virginia Wang
7Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
8Department of Population Health Sciences and Department of Medicine, Duke University, Durham, North Carolina
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Douglas A. Bronson
9Department of Veterans Affairs, Veterans Health Administration, Washington, D.C.
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Mark Wilson
9Department of Veterans Affairs, Veterans Health Administration, Washington, D.C.
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William Gunnar
9Department of Veterans Affairs, Veterans Health Administration, Washington, D.C.
10Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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Steven D. Weisbord
1Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
2Center for Health Equity Research and Promotion, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
6Medical Service, Renal Section, Veterans Health Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Abstract

Background and objectives Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown.

Design, setting, participants, & measurements We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (i.e., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (i.e., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation.

Results Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non–Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).

Conclusions Most dually enrolled veterans underwent transplantation at a non–Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration–only post-transplant care had the lowest 5-year mortality.

  • kidney transplantation
  • transplant outcomes
  • survival
  • veterans
  • Medicare

Introduction

Access to high-quality, timely care is an institutional priority of the Veterans Health Administration (VA). In 2014, the US Congress passed the Veterans Access, Choice, and Accountability Act to expand options for veterans to receive care outside the VA. This legislation resulted in relatively limited utilization of private sector care, as decisions authorizing non-VA care rested primarily with VA personnel (1). In 2019, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSIONs) Act was implemented, increasing the number of veterans eligible for non-VA care, and shifting decisions on the location of care primarily to veterans (2,3). This legislation is particularly relevant to veterans with advanced kidney disease who have no other health insurance. Before the MISSION Act, such veterans were required to travel to designated VA Transplant Centers to undergo kidney transplantation. Past research suggests these veterans were less likely to undergo kidney transplantation than those with private insurance (4,5). Many such veterans will now be able to receive transplant care at qualifying local non-VA transplant facilities.

Although providing veterans more options for transplant care seems advantageous, the implications of greater choice for patient outcomes are unknown. Historically, veterans dually enrolled in VA and Medicare have had the option of receiving transplant care through the VA, or in the private health care sector using Medicare (6). Examining where such veterans elected to receive transplant care and its association with patient outcomes can help gauge the potential clinical implications of the MISSION Act for this population, and inform patient and provider decisions on where to seek transplant care with the expanded choices now offered by this legislation. Accordingly, we conducted a retrospective cohort study to characterize where veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care, and to evaluate the association of post-transplant care source with longer-term mortality.

Materials and Methods

Study Design and Patient Population

This study was supported by the VA National Surgery Office and VA Quality Enhancement Research Initiative as a partnered quality improvement project and was exempt from Institutional Review Board review. The VA tracks all veterans referred for solid organ transplantation at VA Medical Centers using the Transplant Referral and Cost Evaluation/Reimbursement database. We used the Transplant Referral and Cost Evaluation/Reimbursement database to identify all veterans who underwent kidney transplantation at a VA Transplant Center from January 1, 2008 to December 31, 2016. We used International Classification of Diseases 9th Revision (ICD-9) and ICD-10 procedure codes and Current Procedural Terminology codes present in Medicare files, which comprise all Medicare services provided to veterans eligible for VA care, to identify VA-enrolled veterans who underwent Medicare-funded kidney transplantation at a non-VA Transplant Center during this period (Supplemental Table 1).

We excluded a small number of patients not enrolled in both VA and Medicare at the time of transplant, because the focus of this study was on those veterans with the option to receive care within and/or outside VA. To permit comprehensive ascertainment of clinical comorbidities before transplantation, we excluded veterans continuously enrolled in a Medicare Advantage plan for the 12 months preceding transplantation because of a lack of complete encounter data in such patients (Figure 1). Additionally, we excluded veterans continuously enrolled in a Medicare Advantage plan for the 12 months after transplantation to fully capture post-transplant care. We excluded from our primary analyses patients who died within 30 days after kidney transplant, under the assumption that the cause of death was related to surgical complications rather than outpatient post-transplant care. Finally, we linked remaining patients to the United States Renal Data System database and excluded those with no record of transplantation. For patients without any exclusion criteria, we used the United States Renal Data System database to collect data on if, and for how long, patients had been on dialysis before the index transplant, if they had a history of kidney transplantation, and the source of the index transplant (i.e., living versus deceased donor).

Figure 1.
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Figure 1.

Study population. Patients screened, exclusions, and final study cohort. USRDS, United States Renal Data System; VA, Veterans Health Administration.

Post-Transplant Care and Mortality Assessment

We used the VA Corporate Data Warehouse (CDW) to assess post-transplant care delivered within VA and Medicare files to capture Medicare-funded post-transplant care delivered outside the VA. 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. We defined transplant-related outpatient visits as those with an ICD-9 or ICD-10 code specifying kidney transplant as the primary or secondary diagnosis (Supplemental Table 2). We defined immunosuppressive medications as prescriptions dispensed by the VA or paid for by Medicare for oral or intravenous cyclosporine, tacrolimus, mycophenolate, sirolimus, and everolimus. We identified prescriptions in VA and Medicare part D by identifying generic and brand names, and in Medicare Part B using J codes (Supplemental Table 3). We identified blood calcineurin inhibitor level measurement in VA using CDW laboratory files and in Medicare using Current Procedural Terminology codes (Supplemental Table 3).

We categorized the source of post-transplant care as VA only if all such care was provided within VA, Medicare only if all such care occurred outside VA via Medicare, and dual use if any such care was provided through both VA and Medicare, in the year after hospital discharge after kidney transplantation. We used the VA Vital Status File to track all-cause mortality, beginning at the time of discharge from the hospital after transplantation, and continuing through December 31, 2017.

Statistical Analyses

We used cumulative hazard plots to depict 5-year mortality on the basis of the source of post-transplant care. We performed Cox regression analyses to assess the association of source of post-transplant care with 5-year all-cause mortality, adjusting for age at transplantation, sex, race, clinical comorbidities, transplant surgery site (within VA versus outside VA via Medicare), year of transplant, prior kidney transplantation, pretransplant dialysis, duration of prior dialysis, and type of transplant (living versus deceased donor). We identified comorbid conditions on the basis of the conditions documented in the CDW and/or Medicare files in the 12 months preceding surgery. Patients were censored at 5 years of follow-up or on December 31, 2017. We confirmed the proportionality assumption using time-dependent explanatory variables. We tested for a statistical interaction between location of kidney transplantation and source of post-transplant care.

We conducted sensitivity analyses in which we categorized source of post-transplant care separately as VA only, Medicare only, and dual care on the basis of each individual component of care (i.e., outpatient visits, immunosuppressant prescriptions, calcineurin inhibitor measurements). We also conducted sensitivity analyses of additional outcomes, including mortality at 1 year and at the end of study follow-up; need for dialysis and rejection episodes at 1 year; and 5-year mortality in which we excluded patients enrolled in a Medicare Advantage Plan for any month in the year after transplant (instead of continuously for 12 months) and those not enrolled in Medicare at the time of transplantation. Finally, we compared 30-day mortality by site of transplantation and frequency of outpatient transplant clinic visits and calcineurin inhibitor checks on the basis of site of post-transplant care. Patients with missing data were not included in the regression analyses.

We performed all statistical analyses using SAS 7.1 software and defined statistical significance as a two-tailed P value <0.05.

Results

Study Population and Location of Kidney Transplantation

We identified 7682 veterans dually enrolled in VA and Medicare who underwent kidney transplantation in VA or outside VA using Medicare between January 1, 2008 and December 31, 2016. After excluding 1476 with one or more exclusion criteria, 6206 veterans constituted our study cohort (Figure 1). Of these, 975 (16%) underwent kidney transplantation at a VA Transplant Center and 5231 (84%) at a non-VA Transplant Center through Medicare. Compared with veterans transplanted in VA, those transplanted through Medicare were older and more likely to have diagnostic codes for heart, cerebrovascular, and peripheral vascular disease, obstructive lung disease, and rheumatologic disease, but less likely to have diagnostic codes for diabetes (Supplemental Table 4). Additionally, those transplanted through Medicare were more likely to have Medicare parts B and D and Medicaid coverage after transplantation, and higher VA Priority Group scores denoting higher required copayments for VA services. We had missing data on race/ethnicity (n=115), VA priority group (n=178), and donor type (n=1). These patients were not included in the regression analyses.

Source of Post-Transplant Care

In the first year after transplantation, 752 veterans (12%) received post-transplant care in VA only, 2092 (34%) through Medicare only, and 3362 (54%) through both VA and Medicare (Table 1). Veterans who received VA-only post-transplant care were younger and less likely to have diagnostic codes for cardiac, cerebrovascular, and peripheral vascular disease than those with transplant care through Medicare only and dual-care users (Table 1).

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Table 1.

Patient characteristics based on source of post-transplant care

Of veterans transplanted through Medicare, 40% received Medicare-only post-transplant care, while 60% received at least some VA care in the first year after transplant (Supplemental Figure 1, Table 2). Comparatively, 72% of veterans transplanted in VA received VA-only post-transplant care, and 28% received at least some care outside the VA through Medicare. Compared with patients who underwent VA transplantation, those who received a kidney transplant outside VA using Medicare were more likely to receive dual care for transplant-related outpatient visits (56% versus 28%, P<0.001), immunosuppressant prescriptions (22% versus 2%, P<0.001), and calcineurin inhibitor level measurements (19% versus 7%, P<0.001) (Table 2).

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Table 2.

Post-transplant care based on location of transplant surgery

Association of Post-Transplant Care Source with Mortality

Over 5 years of follow-up, 1053 veterans (17%) overall died. Patients who received Medicare-only post-transplant care had a higher 5-year mortality rate compared with patients who were VA only (20% versus 11%, P<0.001), as did patients who were dual care (16% versus 11%, P<0.001) (Figure 2). There was no significant interaction between location of transplantation and source of post-transplant care (P=0.82), so the interaction term was excluded from the final Cox model. In adjusted analyses, the risk of death was higher in patients who were Medicare only (adjusted hazard ratio [HR], 2.2; 95% confidence interval [95% CI], 1.5 to 3.1; P<0.001) and patients who were dual care (adjusted HR, 1.5; 95% CI, 1.1 to 2.1; P=0.02) compared with patients who were VA only after excluding those with missing data (Table 3).

Figure 2.
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Figure 2.

Comparison of 5-year mortality on the basis of the source of post-transplant care. VA, Veterans Health Administration.

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Table 3.

Association of source of post-transplant care with mortality

Sensitivity Analyses

Sensitivity analyses that examined each component of post-transplant care by source of care demonstrated findings similar to our primary analyses, although the higher risk of mortality in the dual-care group for immunosuppressants and calcineurin inhibitor measurements was not statistically significant and certain analyses did not meet the proportionality assumption (Supplemental Table 5). The risks for death at 1 year and at the end of the follow-up period were also higher among patients who were Medicare only or dual care (Table 3). Similarly, when excluding those patients enrolled in a Medicare Advantage plan at any time in the 12 months after transplant, 5-year mortality remained higher in patients who were Medicare only and who were dual care compared with VA only (Table 3). The 5-year mortality rate among veterans transplanted within the VA who were not enrolled in Medicare at the time of the transplant was <5%. We observed lower 30-day mortality among those transplanted within the VA compared with outside the VA (<1% versus 1%, P=0.01), yet no difference in the need for dialysis at 1 year on the basis of site of transplantation (3% in VA versus 3% in Medicare, P=0.81). However, the need for dialysis at 1 year was lower in those who received VA-only post-transplant care than Medicare only (2% versus 3%, P=0.01) and when comparing VA-only post-transplant care with dual care (2% versus 4%, P=0.005). Finally, outpatient transplant clinic visits, calcineurin inhibitor measurements, and rejection episodes were more frequent in those who received Medicare only or dual care (Supplemental Tables 6 and 7).

Discussion

In a cohort of kidney transplant recipients eligible to receive care in VA and/or the private sector using Medicare, more than 80% underwent transplantation at a non-VA Transplant Center using Medicare. However, two thirds received some or all post-transplant care within the VA. Patients who received post-transplant care exclusively through Medicare or through both VA and Medicare had higher mortality than those who received VA-only post-transplant care (7).

There are at least two potential non-mutually exclusive explanations for our findings of lower mortality among veterans who received VA-only post-transplant care. First, the quality of post-transplant care could be higher within the VA. Several prior studies that compared outcomes and quality of nontransplant care between VA and non-VA facilities demonstrated differences favoring VA (8⇓–10). Streja et al. (9) and Wang et al. (10) found lower mortality among veterans who received dialysis within the VA compared with veterans who received this treatment outside the VA. O’Hanlon et al. (8) demonstrated higher-quality diabetes, cardiovascular, and preventive care, and lower rates of inappropriate medication prescribing in VA compared with non-VA facilities. The provision of post-transplant care that minimizes risk for adverse outcomes requires effective coordination among providers, pharmacists, and transplant coordinators. Immunosuppressive agents must be properly dosed and interacting medications avoided, calcineurin inhibitor levels need to be maintained within narrow therapeutic windows, and transplant-related complications require prompt treatment. Several facets of the VA Healthcare System facilitate post-transplant care coordination that may be more challenging to achieve in the private sector. 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 (11,12). Such factors may contribute to more effective coordination of transplant care, which could translate into improved outcomes. Interestingly, the difference in 5-year mortality was smaller when post-transplant care was defined by immunosuppressant medication prescribing than by outpatient transplant-related clinic visits (Supplemental Table 5). As the venue of outpatient transplant visits may better reflect where veterans primarily receive their care, this finding suggests that potential differences in the quality of care could explain our primary findings.

Although we adjusted our analyses for site of transplantation and other potential confounders, an alternative explanation for our survival analyses favoring the VA may be due to transplant system and process differences, resulting in the favorable selection of patients in the VA. For example, VA Transplant Centers may require a more arduous evaluation process that results in the selection of healthier patients for transplantation compared with larger non-VA Centers. They may also be less likely to accept high Kidney Donor Profile Index kidneys, to minimize the number of patients with poor outcomes (13). Our finding of lower 30-day mortality among those transplanted within the VA may support this possibility. The lower rates of dialysis dependence and rejection episodes at 1 year, and lower frequency of outpatient transplant visits and calcineurin inhibitor measurements among those who received VA-only post-transplant care, a large majority of whom were transplanted in the VA, may also suggest a healthier patient population. However, these observations could also reflect differences in the quality of care after transplantation. Further exploration is needed to delineate the effects of post-transplant care quality and/or differential transplant listing on longer-term mortality among veterans receiving care within and across health care systems.

Many veterans in our study were users of dual care after transplantation, particularly those who received a kidney allograft through Medicare. Dual care poses a risk for fragmentation and/or duplication in care, as well as serious adverse outcomes (14⇓⇓⇓–18). Although the effect of dual care on outcomes among transplant recipients has not previously been investigated, a study by Thrall et al. (19) of 46 dual-care veterans with a history of organ transplantation found that more than half had duplicative monitoring of immunosuppressant levels and/or discrepancies in immunosuppressant regimens across health systems. Moreover, just 25% of kidney transplant patients had clinic notes or laboratory results from the non-VA facility scanned into the VA health record. Such dual care could plausibly lead to allograft rejection and other serious, adverse transplant-related complications. If so, this could explain why we found higher mortality among those who used dual post-transplant care compared with patients who were VA only. Nonetheless, our finding of lower mortality among dual-care patients compared with patients who are Medicare only suggests the possibility that some involvement from VA in post-transplant care might benefit patients. Future efforts to elucidate how coordination of transplant care affects patients’ outcomes may lead to improved treatment models in those eligible for care both within and outside VA.

The MISSION Act will enhance the convenience of kidney transplant care for many veterans by obviating the need to travel to a designated VA Transplant Center for such care. This is important as prior studies suggest that veterans without other health insurance were less likely to undergo kidney transplantation than veterans and non-veterans with private insurance (4,5). The extent to which veterans will choose to receive non-VA transplant care using the recently enacted MISSION Act is unknown. Nonetheless, our finding of higher long-term mortality among veterans who receive some or all post-kidney transplant care outside the VA underscores the importance of closely tracking outcomes among those who choose to utilize the MISSION Act to receive transplant care in the private sector.

The recently signed Advancing American Kidney Health Initiative aims to substantially increase the number of kidney transplants in the next decade, including instituting financial incentives and policy proposals to expand the kidney donor pool (20). Consequently, a growing number of patients, including veterans, are likely to receive transplant care in the future. Our findings on the substantial reliance of veterans on the VA for such care have important implications regarding the future allocation of funds to manage this patient population. Furthermore, future Centers for Medicare and Medicaid payment models and financial incentives could consider requirements for more integrated post-transplant care for the lifespan of the organ if additional research confirms that greater coordination of transplant care improves patient outcomes.

Our study has important limitations (13). First, although patients who received VA-only post-transplant care were more likely than patients who were Medicare only or dual care to have received a deceased donor transplant, we did not have access to other donor data such as Kidney Donor Profile Index, type of donor (standard criteria versus extended criteria), or recipients’ calculated panel-reactive antibody levels (21,22). Differences in such variables, if present, could affect longer-term outcomes. Nonetheless, the E-value associated with our lower point estimate (i.e., adjusted HR, 1.5; 95% CI, 1.1 to 2.1) suggests that an unmeasured confounder would need to have a HR of 2.37 to negate our findings, which seems unlikely (23). Second, we did not have access to data on post-transplant care paid for by private insurance and, hence, we did not include veterans who were eligible for but not enrolled in VA. Although administrative claims data should capture all such care, we were unable to identify immunosuppressant medication prescriptions in 12% of Medicare transplant patients in the year after transplant, despite their eligibility for continued Medicare payment of these medications (24). Third, we considered post-transplant care in the first 12 months after hospital discharge from transplantation as our exposure variable rather than a more sustained period of time, as the first year is typically the most intensive period of post-transplant management. Fourth, we selected a study endpoint (i.e., 5-year mortality) that is not the only potential quality of care outcome. We considered alternative outcomes, but limited power and lack of access to certain data sources precluded investigating other outcomes. Finally, we cannot confirm that the observed associations of post-transplant care source with death are causal. We also acknowledge that the post-transplant care veterans received using Medicare may not necessarily reflect the care they will receive with the MISSION Act. For example, care delivered via the MISSION Act will be documented as scanned notes in the VA electronic medical record, whereas Medicare-funded care has no such requirement.

In summary, in a national cohort of kidney transplant recipients dually enrolled in VA and Medicare, use of VA for post-transplant care is common, even among those undergoing transplantation outside VA, and is associated with lower mortality than receipt of such care via Medicare or both VA and Medicare. Future studies will help clarify the reason(s) for these differences. Nonetheless, our findings can inform patient decisions regarding the preferred venue of care after kidney transplantation and highlight the critical importance of monitoring patient outcomes as the VA expands options for care in the community.

Disclosures

D.A. Bronson reports employment with the Department of Veterans Affairs. M.J. Fine reports employment with VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion. M.K. Mor reports employment with the VA Pittsburgh Healthcare System. M. Ramkumar reports employment with VA Pittsburgh Healthcare System and University of Pittsburgh. M. Wilson reports employment with the VA and other interests/relationships with University of Pittsburgh. S. Rogal reports employment with VA Pittsburgh Healthcare System and University of Pittsburgh, and serving as a scientific advisor or member of the American Association for the Study of Liver Diseases and the American Society for Transplantation. S.D. Weisbord reports employment with the University of Pittsburgh Medical Center; consultancy agreements with Cytokinetics, Durect, and Takeda; and serving as an associate editor for BMC Nephrology. W. Cashion reports employment with University of Pittsburgh Medical Center Presbyterian and University of Pittsburgh. W.F. Gellad reports employment with Department of Veterans Affairs. V. Wang reports employment with Duke University and Durham VA Health Care System; receiving research funding from National Institutes of Health, Department of Veterans Affairs, Centers for Medicare and Medicaid Services, and Agency for Healthcare Research and Quality; and receiving grant reviewer honoraria from National Institutes of Health. All remaining authors have nothing to disclose.

Funding

This work was supported by Department of Veterans Affairs award PEC18-328. W. Cashion was supported by National Institutes of Health grant T32 DK061296.

Acknowledgments

The opinions offered in the manuscript are those of the authors and do not necessarily represent the views of the US Government or Department of Veterans Affairs.

Supplemental Material

This article contains the following supplemental material online at http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.10020620/-/DCSupplemental.

Supplemental Table 1. Codes used to identify kidney transplant recipients.

Supplemental Table 2. Procedural and diagnostic codes used to identify kidney transplant recipients.

Supplemental Table 3. Codes to identify immunosuppressant prescriptions and CNI measurements.

Supplemental Table 4. Patient characteristics based on site of transplantation.

Supplemental Table 5. Association of source of care with 5-year mortality for individual components of care.

Supplemental Table 6. Post-transplant care clinic visits and calcineurin inhibitor measurements by site of post-transplant care.

Supplemental Table 7. Frequency of rejection at 1 year post-transplant based on site of post-transplant care.

Supplemental Figure 1. Post-transplant care by site of transplant surgery.

Footnotes

  • Published online ahead of print. Publication date available at www.cjasn.org.

  • See related editorial, “Post-Kidney Transplant Care and Health Outcomes of US Veterans,” on pages 337–339.

  • Received June 19, 2020.
  • Accepted December 21, 2020.
  • Copyright © 2021 by the American Society of Nephrology

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Clinical Journal of the American Society of Nephrology: 16 (3)
Clinical Journal of the American Society of Nephrology
Vol. 16, Issue 3
March 08, 2021
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Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare
Winn Cashion, Walid F. Gellad, Florentina E. Sileanu, Maria K. Mor, Michael J. Fine, Jennifer Hale, Daniel E. Hall, Shari Rogal, Galen Switzer, Mohan Ramkumar, Virginia Wang, Douglas A. Bronson, Mark Wilson, William Gunnar, Steven D. Weisbord
CJASN Mar 2021, 16 (3) 437-445; DOI: 10.2215/CJN.10020620

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Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare
Winn Cashion, Walid F. Gellad, Florentina E. Sileanu, Maria K. Mor, Michael J. Fine, Jennifer Hale, Daniel E. Hall, Shari Rogal, Galen Switzer, Mohan Ramkumar, Virginia Wang, Douglas A. Bronson, Mark Wilson, William Gunnar, Steven D. Weisbord
CJASN Mar 2021, 16 (3) 437-445; DOI: 10.2215/CJN.10020620
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