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

Abstract

Background and objectivesMany 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, & measurementsWe 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.ResultsAmong 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).ConclusionsMost 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.

Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery

“…2,3,5,36 However, numerous studies comparing the quality of preventive services, primary care, mental health care, oncology, posttransplant care, and surgical specialties suggest VHA performs better, comparable with, or less vari- ably relative to the private sector. 4,6,[12][13][14][37][38][39][40][41][42] Because surgical care is both high risk and costly, understanding the most appropriate surgical care setting for veterans is critical for informing current and future health policy decisions and budget appropriations. 43 In this context, our study supports 2 important conclusions.…”

“…Throughout the past decade, major legislation has relaxed eligibility criteria for veterans to access nonurgent care outside of the VA and more veteran health care has shifted to the private sector . However, numerous studies comparing the quality of preventive services, primary care, mental health care, oncology, posttransplant care, and surgical specialties suggest VHA performs better, comparable with, or less variably relative to the private sector . Because surgical care is both high risk and costly, understanding the most appropriate surgical care setting for veterans is critical for informing current and future health policy decisions and budget appropriations .…”

Association of hemoglobin A1c stability with mortality and diabetes complications in older adults with diabetes

“…We studied veterans, who tend to have higher comorbidities than non-veterans, 29 30 and their reliance on VA healthcare may influence coding of complications or differences in outcomes by treatment setting. 31 A1c TIR as a clinically derived construct was calculated by linear interpolation between A1c tests obtained in usual care, which may introduce some measurement error. In addition, the requirement for four or more A1c tests during the baseline period may lead to selection bias since patients with fewer tests were not included.…”

Association of hemoglobin A1c time in range with risk for diabetes complications

“…Greater reliance on VA could influence complications through differences in treatment practices by setting. 48 Complications were assessed using coded data and reflect how clinicians code for different conditions. VA clinicians may be less focused on exact coding because only a minority of patients have external billing.…”

“…Furthermore, we studied military Veterans, who have higher comorbidities than non-Veteran peers46 47 and were selected because of regular use of VA healthcare services. Greater reliance on VA could influence complications through differences in treatment practices by setting 48. Complications were assessed using coded data and reflect how clinicians code for different conditions.…”