BACKGROUND/RATIONALE:
In 1999, more than 4,400 patients received hemodialysis in Veterans Affairs (VA) facilities at an estimated cost over $60 million. However, dialysis is a limited resource in the VA, and some VAs may require additional fee-basis care to meet patients’ needs. The total costs of care and impacts on patients’ outcomes of receiving care in VA or non-VA dialysis facilities are not known. If in fact large differences in care costs or outcomes do exist, hemodialysis care options for the VA may need to be changed.

OBJECTIVE(S):
This prospective observational study examined the complex incentives for care for end stage renal disease (ESRD) patients in 8 VA facilities. The primary objective was to determine whether costs of providing ESRD care and health-related quality of life (HRQOL) differed for veterans who received their hemodialysis at VA versus non-VA facilities.

METHODS:
Veterans were recruited from August 2001 through December 2003. Patients were followed for six months, or if they were new dialysis patients, 12 months. Data collected included demographics, clinical characteristics and health-related quality of life (HRQOL). Total health care costs for all patients were computed using micro-costing analyses, Medicare’s Renal Cost Reports, and VA and Medicare administrative databases.

FINDINGS/RESULTS:
Three hundred sixty-four veterans consented to participate in the study and 344 were subsequently enrolled: 188 dialyzing in VA facilities, 132 dialyzing in private-sector facilities, and 24 dialyzing at private-sector facilities as VA fee-basis patients. There were significant differences in age, race, marriage status and distance from the VA between the 3 groups of patients, with patients dialyzing at the VA younger, more African-American, less likely to be married, and living closer to the VA. The 132 veterans dialyzing at non-VA facilities were more likely to have insurance supplemental to Medicare and VA, either in the form of Medicaid or private insurance. Patients dialyzing at the VA were significantly more ill according to several health status measures: lower hemoglobin and albumin, more complications with diabetes and more drug dependence. HRQOL was not significantly different between the 188 patients dialyzing at the VA and the 156 (fee-basis included) dialyzing at non-VA facilities; patients dialyzing at VA facilities were more likely to report higher levels of staff encouragement.

IMPACT:
Findings from this study have been continuously reported at meetings and one manuscript has been submitted. Three related manuscripts focusing on trends in ESRD care have also been completed, supported in part by this project. Five additional manuscripts are in progress. Findings from this study have provided the basis for two subsequent studies: one led by Dr. Stroupe to investigate the predialysis phase of care and further characterize the dual insurance aspects affecting health care choice (IIR-02-244), and a new proposal to evaluate a chronic disease management program to improve the processes that will better identify and improve primary care for chronic renal failure patients. This ESRD cost-effectiveness study is among the first to compare patients who receive dialysis care at VA vs. non-VA facilities,. Veterans dually eligible for VA and Medicare benefits are of particular interest to VA and Medicare policymakers. Evaluating the alternative methods for dialysis provision and ESRD care in general will allow VA to determine whether provision of ESRD care by VA facilities, non-VA facilities, or both is the most efficient method.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Hynes DM, Stroupe KT, Kaufman JS, Reda DJ, Peterman A, Browning MM, Huo Z, Sorbara D. Adherence to guidelines for ESRD anemia management. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2006 Mar 1; 47(3):455-61. [view]
2. Hynes DM, Stroupe KT, Fischer MJ, Reda DJ, Manning W, Browning MM, Huo Z, Saban K, Kaufman JS, for ESRD Cost Study Group. Comparing VA and private sector healthcare costs for end-stage renal disease. Medical care. 2012 Feb 1; 50(2):161-70. [view]
3. Saban KL, Stroupe KT, Bryant FB, Reda DJ, Browning MM, Hynes DM. Comparison of health-related quality of life measures for chronic renal failure: quality of well-being scale, short-form-6D, and the kidney disease quality of life instrument. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2008 Oct 1; 17(8):1103-15. [view]
4. Hynes DM, Stroupe KT, Greer JW, Reda DJ, Frankenfield DL, Kaufman JS, Henderson WG, Owen WF, Rocco MV, Wish JB, Kang J, Feussner JR. Potential cost savings of erythropoietin administration in end-stage renal disease. The American journal of medicine. 2002 Feb 15; 112(3):169-75. [view]

Conference Presentations

1. Hynes DM, Stroupe KS, Browning MM, Kaufman JS, Reda DJ, Peterman A, Huo Z. Adherence Guidelines for ESRD Anemia Management: Implications for Cost and Quality of Care. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
2. Stroupe KT, Hynes DM, Kaufman JS, Reda DJ, Browning MM, Huo Z, Arnold N. Cost of End-Stage Renal Disease Care for Veterans Receiving Dialysis in VA vs. Non-VA Facilities. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
3. Stroupe KT, Hynes DM, Colin PM. Pre-planning for Initiation of Dialysis at VA Medical Centers: Implications for Quality of Care. Paper presented at: VA HSR&D National Meeting; 2002 Feb 1; Washington, DC. [view]
4. Stroupe KT, Hynes DM, Koelling K. VA and Medicare-covered private-sector healthcare use by veterans with end stage renal disease. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 1; San Diego, CA. [view]

DRA: Health Systems
DRE: Epidemiology
Keywords: Chronic disease (other & unspecified), Cost effectiveness, VA/non-VA comparisons
MeSH Terms: none