What is the clinical evidence from this study?

Study design: Cohort. Population: End-Stage Renal Disease (ESRD) initiating chronic dialysis (n=27241). Intervention: Exclusively VA dialysis vs. Exclusively Medicare-financed dialysis. Primary outcome: 2-year all-cause mortality (HR 0.84, 95% CI 0.73-0.96, p=0.01).

November 30, 2018

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings

Q: What does this research mean for the field?

Veterans receiving dialysis exclusively in VA facilities have a significantly lower 2-year mortality rate compared to those receiving dialysis exclusively through Medicare. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

VWVirginia WangDuke University CCCynthia J. CoffmanDuke University KSKaren M. StechuchakDurham VA Health Care System

Key Result

Veterans receiving dialysis exclusively in VA facilities had a significantly lower 2-year mortality rate compared to those receiving dialysis exclusively through Medicare (HR 0.84).

Study Design

Type

Cohort (n=27,241)

Multicenter

Yes

Structured PICO

Does receiving dialysis in VA facilities, VA-PC, or dual settings reduce 2-year mortality compared to Medicare-financed dialysis in veterans with ESRD?

Population

27,241 VA-enrolled veterans with ESRD who initiated maintenance dialysis between 2008 and 2011. Mean age 71 years, 98% men, 67% white. Excluded: received a renal transplant, died within the first 90 days, recovered renal function within the first 180 days, lived outside the US, incomplete demographic/clinical info, enrolled in Medicare Advantage, no outpatient dialysis claims, or hospitalized throughout follow-up.

Intervention

Dialysis treatment in exclusively Veterans Affairs (VA) facilities, exclusively VA Purchased Care (VA-PC) community clinics, or dual settings (more than one setting) over a 2-year period.

Comparator

Exclusively Medicare-financed community-based dialysis.

Outcome

All-cause mortality after the first 90 days up to 2 years after dialysis initiation.hard clinical

Veterans with ESRD receiving dialysis in VA facilities or across multiple settings had significantly lower 2-year mortality compared to those receiving exclusively Medicare-financed community dialysis.

Main Result

Effect estimate: HR 0.84 (95% CI 0.73-0.96)

Absolute Event Rate: 32% vs 37%

p-value: p=0.01

Limitations

Results may not generalize to veterans receiving dialysis through Medicare Advantage or private insurance.
Analyses may not reflect current trends in CMS and VA payment and contracting policy, which have changed since 2012.
Subject to unmeasured confounding, especially pertaining to care during the pre-dialysis period and social support.
Unable to examine intermediate outcomes of dialysis treatment (e.g., urea reduction ratio, anemia treatment) due to limited availability of laboratory data from non-VA settings.
Unable to identify or characterize VA-PC providers from the VA-PC claims.

Abstract

BACKGROUND: Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements. METHODS: ) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics. RESULTS: Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings. CONCLUSIONS: Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.

Ask AI

Helpful

Bookmark

View Full Paper