*Purpose: The Veterans Affairs (VA) Maintaining Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 was implemented in 2019 to increase veteran access to both VA and non-VA healthcare centers. Given limited VA transplant centers (VATCs), increased access to more geographically convenient non-VA transplant centers could have substantial effects on VATC utilization. We aimed to assess the impact of the MISSION Act on utilization of VATCs. All veterans require a referral to Transplant Referral and Cost Evaluation/Reimbursement (TRACER) system to be considered for transplant either at VATCs or to request community care funding for a transplant center external to the VA.

*Methods: Data from the VA TRACER system were used to perform descriptive analyses of candidate transplant referrals in the 14 months pre- (April 2018 – June 5, 2019) and post- (June 6, 2019 – September 2020) implementation of the MISSION Act. Utilization of VATC for transplant evaluation (evaluations performed at VATC / referrals received by VATC) was used in multivariable logistic regression models to evaluate effects of MISSION Act era and candidate characteristics on likelihood of utilization of VATC.

*Results: 4872 first/only transplant referrals were received during the study period (2351 pre-MISSION; 2521 post-MISSION). There were no statistically significant differences in candidate demographics (61.3 vs 61.1 years; 94.8% male vs 94.4% male; 59.2% white vs 62.1% white; 86.9% non-Hispanic vs 88.5% non-Hispanic; 55.3% married vs 55.8% married; all p>0.05) between eras, nor were there substantial differences in clinical eligibility (78.6% eligible vs 80;8% eligible; 96% stable vs 94.8% stable). More veterans were evaluated for transplant (5.7% vs 16%) and transferred outside of the VA (0.3% vs 9.4%) in the post-MISSION Act era. Of veterans expressing a preference, most intended to be listed at only a VATC (56.2%) rather than a community transplant center (12.7%) or both (31.1%). Multivariable logistic regression model of the utilization of VATC by MISSION Act era showed that, when adjusted for candidate characteristics, there was a decreased odds of utilization of VATC in the post-MISSION Act era (p<0.001) (Table 1).

*Conclusions: Utilization of VATCs has decreased in the post-MISSION Act era. Careful attention to patterns and preferences for veteran transplant candidates can inform future policy and funding decisions.

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