Access to kidney transplantation among patients insured by the United States Department of Veterans Affairs

Abstract

Ensuring equal access to kidney transplantation is of paramount importance. Veterans that receive care from the Department of Veteran Affairs (VA) must complete a complex process to be placed on the transplant wait-list, and only four VA hospitals in the United States transplant kidneys. This unique system may cause VA patients to wait longer for kidney transplants than other patients. We compared the time to transplantation among ESRD patients insured by the VA to those insured by private insurance or Medicare/Medicaid. Of 7395 veterans studied, 9.3% received transplants, compared to 35,450 of 144,651 (24.5%) patients with private insurance and 36,150 of 357,345 (10.1%) patients with Medicare/Medicaid insurance (P < 0.0001). We found that both VA-insured and Medicare/Medicaid-insured patients were approximately 35% less likely to receive transplants than patients with private insurance (hazard ratio [HR] 0.65; 95% CI 0.60 to 0.70; P < 0.0001). Most of this difference was explained by the fact that VA patients were less likely to be placed on the wait-list (HR 0.71; 95% CI 0.67 to 0.76), but even listed VA patients received transplants less frequently than those insured privately (HR 0.89; 95% CI 0.82 to 0.96). Interestingly, VA patients with supplemental private insurance had the same likelihood of transplantation as non-VA patients with private insurance. We conclude that VA-insured patients are less likely to receive transplants than privately insured patients, and that further studies are needed to identify the reasons for this disparity.