Significantly Lower Rates of Kidney Transplantation among Candidates Listed with the Veterans Administration: A National and Local Comparison

Abstract

Background: The process for evaluating kidney transplant candidates and applicable centers is distinct for patients with Veterans Administration (VA) coverage. We compared transplant rates between candidates on the kidney waiting list with VA coverage and those with other primary insurance.

Methods: Using the Scientific Registry of Transplant Recipients database, we obtained data for all adult patients in the United States listed for a primary solitary kidney transplant between January 2004 and August 2016. Of 302,457 patients analyzed, 3663 had VA primary insurance coverage.

Results: VA patients had a much greater median distance to their transplant center than those with other insurance had (282 versus 22 miles). In an adjusted Cox model, compared with private pay and Medicare patients, VA patients had a hazard ratio (95% confidence interval) for time to transplant of 0.72 (0.68 to 0.76) and 0.85 (0.81 to 0.90), respectively, and lower rates for living and deceased donor transplants. In a model comparing VA transplant rates with rates from four local non-VA competing centers in the same donor service areas, lower transplant rates for VA patients than for privately insured patients persisted (hazard ratio, 0.72; 95% confidence interval, 0.65 to 0.79) despite similar adjusted mortality rates. Transplant rates for VA patients were similar to those of Medicare patients locally, although Medicare patients were more likely to die or be delisted after waitlist placement.

Conclusions: After successful listing, VA kidney transplant candidates appear to have persistent barriers to transplant. Further contemporary analyses are needed to account for variables that contribute to such differential transplant rates.

Keywords: cadaver organ transplantation; kidney transplantation; transplant outcomes.

Figure 1.

Flow chart of patient inclusion/exclusion.

Figure 2.

Time to transplantation or death in VA patients versus patients with private or Medicare insurance at four local competing non-VA centers.

Figure 3.

HRs (95% CIs) for transplantation, death, and removal from the waiting list in VA patients versus patients with private insurance from four local non-VA centers. D, donor.