VA Health Care:
Additional Training Could Improve Organ Transplant Referral and Evaluation Processes
GAO-20-4: Published: Oct 2, 2019. Publicly Released: Oct 2, 2019.
If a veteran needs a transplant (such as a kidney), the Department of Veterans Affairs has 12 solid organ transplant centers around the country. Veterans are initially screened at a VA medical center, which can refer them to a transplant center.
The transplant center typically has 30 days to evaluate and decide whether the veteran continues the process—the next step being placement on the national organ waitlist.
VA almost always met its referral timeliness standard and generally improved the speed of evaluations from 2014 through 2018. We recommended that VA provide additional training to speed transplant referrals and evaluations.
VA Transplant Centers Providing Solid Organ Transplants as of June 2019
Map showing 12 locations across the contiguous United States
What GAO Found
The 12 Veterans Affairs' transplant centers (VATC), which are overseen by the Veterans Health Administration (VHA), almost always met the referral timeliness standard from fiscal years 2014 through 2018. When a veteran is determined to be a potential candidate for an organ transplant, he or she can receive a formal referral to a VATC. Depending on the type of referral, the VATC must meet specific timeliness standards for reviewing the referral and deciding if the veteran should receive a full evaluation. Likewise, VATCs have timeliness standards for conducting the full evaluation, and generally showed improvement in meeting that standard from fiscal years 2014 through 2018. For those delays in conducting full evaluations that did occur, GAO found they varied by organ type and VATC. Specifically, in fiscal year 2018, transplant evaluation timeliness ranged from 60 percent at two VATC kidney programs to 100 percent at kidney, liver, heart or lung programs across seven different VATCs.
Percentage of Timely Referral Reviews and Evaluations by Department of Veterans Affairs Transplant Centers from Fiscal Years 2014 through 2018
According to VATC officials, transplant evaluation delays are caused when patients or caregivers are not available or not aware that they are required to be evaluated within 30 days of being referred. Although veterans may prefer to be seen at a later date, untimely evaluations can delay veterans' placement on the national organ donation waitlist. According to VHA data, 192 of the 1,617 transplant evaluation appointments completed in fiscal year 2018 did not meet the 30-day requirement. VATC officials said this was because veterans were not available or not aware of the requirement. GAO found that staff at referring VHA medical centers lacked a full understanding of the transplant referral and evaluation process. For example, VATC providers told GAO that transplant referrals are sometimes incomplete, requiring providers to spend extra time searching for information that should have been readily available. GAO found that additional training for medical center staff would help to improve the efficiency of the transplant referral process and the timeliness of transplant evaluations provided to veterans, a critical factor affecting veteran outcomes.
Why GAO Did This Study
As of June 2019, over 113,000 people in the United States—including veterans—were waiting for an organ transplant. In 2018, more than 36,000 organ transplants were performed at transplant centers across the country, including those within the Department of Veterans Affairs' (VA) Organ Transplant Program.
GAO was asked to review how VA administers and oversees its organ transplant program. This report, among other things, examines the process and timeliness with which VA reviews referrals and completes evaluations for organ transplants.
GAO reviewed data from VHA's Transplant Referral and Cost Evaluation Reimbursement database, documents related to VA's transplant program, and federal internal control standards. GAO conducted site visits to three of the 12 VATCs, selected to obtain diversity in geography and types of organs transplanted. At the selected VATCs, GAO reviewed facility data and documents related to organ transplants and interviewed officials. GAO also collected and reviewed information from the remaining nine VATCs.
What GAO Recommends
VHA should provide additional training for staff at VHA medical centers that refer patients for organ transplants on (1) submitting complete referrals and (2) understanding and communicating the veteran's role related to timely completion of transplant evaluations.
VA concurred in principle with the recommendation and described actions the department will take to address the recommendation.
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Recommendation for Executive Action
Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Recommendation: The Under Secretary for Health should establish a requirement that VHA's National Surgery Office provide additional training to staff at referring VHA medical centers on (a) submitting referral packets through TRACER that are complete, and (b) understanding and communicating the veteran's role in the evaluation process related to the timely completion of transplant evaluations. (Recommendation 1)
Agency Affected: Department of Veterans Affairs