Stroupe KT (Center for Management of Complex Chronic Care), Fischer MJ
(Center for Management of Complex Chronic Care), Hynes DM
(Center for Management of Complex Chronic Care/VIReC), O'Hare AM
(Seattle VA Medical Center), Browning MM
(Center for Management of Complex Chronic Care), Sohn MW
(Center for Management of Complex Chronic Care), Huo Z
(Center for Management of Complex Chronic Care), Kaufman JS
(VA Boston Healthcare System)
In chronic kidney disease patients, timely nephrology care before dialysis initiation is associated with better health outcomes after dialysis initiation. Moreover, clinical guidelines recommend permanent vascular access (PVA) placement before dialysis initiation to avoid temporary catheters, which are associated with excess morbidity, mortality, hospitalization, and cost. There is limited information about the role of the healthcare system (VA/non-VA) in determining receipt of appropriate predialysis care. We examined the impact of healthcare system use on the likelihood of timely predialysis nephrology care and predialysis PVA placement.
We conducted retrospective cross-sectional analyses of veterans and non-veterans eligible for Medicare at least one year before initiating hemodialysis in 2000-2001. Based on overall outpatient care during the 12-month predialysis period, we compared veterans to non-veterans (n = 54,927), further classifying veterans as VA-only (n = 1,394), Medicare-only (n = 3,093), or dual (VA+Medicare) healthcare users (n = 3,545). We used multiple regression analyses to examine associations of healthcare system use with the probability of any predialysis nephrology care, early predialysis nephrology care ( > = 6 months before dialysis initiation), and predialysis PVA placement.
Predialysis nephrology care occurred in 66% of VA-only, 66% of dual, 58% of Medicare-only veterans, and 52% of non-veterans (P < 0.001). Non-veterans were ~20% less likely than VA-only veterans to have any predialysis nephrology care (non-veterans: risk ratio [RR]:0.81, 95% CI:0.78-0.62; Medicare-only veterans: RR:0.91, CI:0.86-0.95; dual veterans: RR:1.02, CI:0.97-1.07). Early predialysis nephrology care occurred in 32% of VA-only, 27% of dual, 17% of Medicare-only veterans, and 17% of non-veterans (P < 0.001). Non-veterans were ~40% less likely than VA-only veterans to have early nephrology care (non-veterans: RR:0.57, CI:0.52-0.62; Medicare-only veterans: RR:0.56, CI:0.50-0.62; dual veterans: RR:0.86, CI:0.78-0.94). Only 26% of VA-only veterans had predialysis PVA placement. Non-veterans were as likely as VA-only veterans to receive predialysis PVA (non-veterans: RR:1.07, CI:0.97-1.18; Medicare-only veterans: RR:1.14, CI:1.02-1.28; dual veterans: RR:1.33, CI:1.20-1.49).
VA-only veterans were more likely to have timely predialysis nephrology care than non-veterans. However, VA-only veterans had similar low rates of predialysis PVA as non-veterans.
Although veterans using VA-only outpatient care had better access to timely predialysis nephrology care than non-veterans, additional efforts to improve PVA placement are warranted to reduce excess morbidity, mortality, hospitalization, and cost.