Background: Low rates of referral to specialty care among Veterans represent a significant barrier to access and optimal clinical outcomes. This is particularly true for Veterans with end-stage organ diseases (e.g., advanced chronic kidney disease (CKD), decompensated cirrhosis), who are potentially eligible for life-saving transplantation and require specialty care for optimal disease management. Despite the high prevalence of end-stage liver and kidney diseases among Veterans, less than a third of Veterans with advanced CKD and decompensated cirrhosis are referred to a specialist and <5% for transplant evaluation. A comprehensive assessment of patient-, provider- and system-level factors influencing specialty care referral and referral for transplant evaluation is critical to developing targeted strategies and approaches to optimize referral appropriateness as there is a clear association between being seen by a specialist and improved survival. Significance/Impact: Ensuring timely access to high-quality primary and specialty care is a core mission of the Veterans Health Administration (VHA). Factors affecting specialty care referral and referral for transplant evaluation among Veterans with advanced chronic liver and kidney diseases are incompletely characterized. This knowledge is critical to designing effective strategies to enhance referral appropriateness and optimize access. Hence, there is an urgent unmet need to improve our understanding of these complex relationships and the mechanisms by which they affect referral to specialty care and referral for transplant evaluation. Innovation: Most existing work has focused on steps downstream of referral to specialty care and for transplant evaluation, such as completion of transplant evaluation, waitlisting, transplant receipt, and post- transplant outcomes -- thus, barriers to specialty care referral and referral for transplant evaluation remain understudied. This study will comprehensively examine and identify the multi-level factors driving referral to specialty care and referral for transplant evaluation, with the goal of generating best practice recommendations to optimize referral appropriateness and equity. This knowledge is critical to improving referral processes/pathways, enhancing Veteran outcomes, and informing policy changes to increase parity in access. Aims: 1) Characterize the multi-level factors associated with specialty referral and referral for transplant evaluation among patients with advanced chronic liver and kidney diseases. 2) Examine patient and provider knowledge, attitudes, and perceived barriers/facilitators of specialty care referral and referral for transplant evaluation. 3) Develop best practice recommendations to optimize referral appropriateness and equity using modified Delphi panels. Project Methods: Aim 1 is a retrospective observational cohort study using multi-level modeling to identify key patient-, provider-, and system-level factors associated with non-referral to specialty care and for transplant evaluation. As part of Aim 1, the impact of social determinants of health on referral to specialty care and for transplant evaluation also will be evaluated. In Aim 2, we will conduct semi-structured qualitative interviews with primary and specialty care providers and patients sampled from 6 VA health systems to explore variation in knowledge, attitudes, and perceived barriers/facilitators of referral to specialty care and for transplant evaluation. In Aim 3, we will use a modified Delphi approach to convene two panels of VA operational leaders and other experts to develop best practice recommendations to maximize referral appropriateness and equity. Implementation/Next Steps: This study will provide critical information regarding key factors impacting specialty care referral and referral for transplant evaluation among vulnerable Veterans with advanced chronic liver and kidney diseases. Products of the grant will provide vital information to VHA leaders on how to enhance referral appropriateness and equity by generating actionable strategies to address key barriers to referral to specialty care and for transplant evaluation.

Providing timely access to high-quality primary and specialty care for Veterans is a core mission of the Veterans Health Administration. Low rates of specialty care referral among Veterans represent a significant barrier to access and optimal clinical outcomes. This is particularly true for Veterans with advanced chronic kidney and liver diseases who are potentially eligible for life-saving transplantation and benefit from specialty expertise in optimizing overall care quality and outcomes. Our proposed research will comprehensively examine and identify key patient-, provider- and system-level factors influencing referral to specialty care and referral for transplant evaluation among these vulnerable Veterans and explore patient and provider perspectives regarding barriers to and facilitators of referral. This information is key to informing development of robust best practice recommendations to optimize referral appropriateness and equity among Veterans with advanced chronic liver and kidney diseases.