Virginia Wang1,2,3, Cynthia J Coffman4,5, Karen M Stechuchak4, Theodore S Z Berkowitz4, Paul L Hebert6,7, David Edelman4,3, Ann M O'Hare6,8, Susan T Crowley9,10, Hollis J Weidenbacher4, Matthew L Maciejewski4,2,3. 1. Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina; virginia.wang@va.gov. 2. Department of Population Health Sciences. 3. Division of General Internal Medicine, Department of Medicine, and. 4. Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina. 5. Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina. 6. Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington. 7. Department of Health Services, School of Public Health and. 8. Department of Medicine, University of Washington, Seattle, Washington. 9. Renal Section, Medical Services, Veterans Affairs Connecticut Health Care System, West Haven, Connecticut; and. 10. Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.
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: We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) 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.
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: We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) 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.
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