Kidney Week

Abstract: SA-OR073

Significantly Lower Rates of Transplantation and Increased Wait List Mortality among Kidney Transplant Candidates with VA Insurance

Session Information

• Transplant Economics and Live Donor Outcomes
  November 04, 2017 | Location: Room 390, Morial Convention Center
  Abstract Time: 04:54 PM - 05:06 PM

Category: Transplantation

• 1702 Transplantation: Clinical and Translational

Authors

• Augustine, Joshua J., Cleveland Clinic, Cleveland, Ohio, United States

Joshua J. Augustine, MD



https://my.clevelandclinic.org/staff/21735-joshua-augustine#biography

• Arrigain, Susana, Cleveland Clinic, Cleveland, Ohio, United States

Susana Arrigain,

• Balabhadrapatruni, Krishna P., Cleveland VAMC, Case Western Reserve University, Cleveland, Ohio, United States

Krishna P. Balabhadrapatruni,

• Desai, Niraj, Cleveland VAMC, Case Western Reserve University, Cleveland, Ohio, United States

Niraj Desai,

• Schold, Jesse D., Cleveland Clinic, Cleveland, Ohio, United States

Jesse D. Schold,

Background

Military veterans do not incur cost for kidney transplantation within the VA system, but transplant availability has historically been limited to just four VA centers nationwide. Recent SRTR reports show a lower observed vs. expected rate of transplant in VA centers. Because VA centers are affiliated with non-VA academic centers within the same donor service area (DSA), we sought to compare transplantation rates nationally and also between the four VA centers and their non-VA (NVA) affiliates.

Methods

SRTR data was used to identify adult patients listed for a primary kidney transplant from 2004 through 2016. Patients with VA insurance (n=3663) were compared to those with private insurance (PI) (n=141,523), Medicaid (n=25,245) and Medicare (n=132,026). Analyses were conducted using multivariable Cox and competing risks regression models for time to transplantation, and unadjusted cumulative incidence functions of death with transplant as a competing risk.

Results

Compared to PI, VA patients were older and mostly male, with more black patients, diabetes, and vascular disease. VA patients lived much further from the transplant center compared to other groups (med. 282 vs. 23 miles). VA patients had a lower likelihood of transplantation compared to PI nationally (HR: 0.72(95% CI:0.69,0.76)), and compared to PI patients within the four NVA programs (HR: 0.78(95% CI:0.71,0.85). This difference with NVA centers persisted after excluding living donors (HR of 0.84(95% CI:0.76,0.93)), and in a model with death as a competing risk. VA patients also had a lower rate of transplantation vs. Medicare nationally (HR of 0.86(95% CI:0.82,0.91)) but did not differ from Medicare in the NVA centers. The HR of VA vs. Medicaid was not different nationally (HR 1.01(0.95,1.06)). The unadjusted cumulative incidence of waitlist mortality at 2 years was 7.0(95% CI:6.1,7.9) in VA patients, 5.8(5.6,5.9) in PI nationally, and 4.6(3.9,5.3) in PI within NVA centers.

Conclusion

VA patients had a lower rate of transplantation and greater waitlist mortality compared to PI patients both nationally and within four paired NVA academic centers that shared DSAs. The reasons for this discrepancy require further study, but may include differences in patient availability and organ acceptance between VA and non-VA centers.