Fischer MJ (Jesse Brown VAMC/Hines VA Hospital), Stroupe KT
(Hines VA Hospital), Kaufman JS
(Boston VAMC), O'Hare AM
(Seattle VAMC), Browning MM
(Hines VA Hospital), Huo Z
(Hines VA Hospital), Hynes DM
(Hines VA Hospital)
Nephrology care before the onset of dialysis lessens complications of end-stage renal disease, facilitates preparation for dialysis, and improves survival after dialysis initiation. Although access to nephrology care may be related to the system in which healthcare is provided, it is unknown whether receipt of nephrology care in different healthcare systems leads to similar dialysis-related health outcomes.
We conducted a retrospective analysis among veterans who initiated hemodialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage (age > =66 years). We used multivariable logistic regression, controlling for demographic and disease characteristics, to examine associations between venue of nephrology care (VA-Only, Medicare-Only, Cross-system [VA+Medicare]) in the 12 months preceding dialysis initiation and important dialysis-related health parameters, including 1-year mortality on dialysis and severe anemia (hemoglobin < 9 g/dL) and permanent hemodialysis vascular access at dialysis initiation.
Among 8,107 veterans in our study, 5,043 (62%) received predialysis nephrology care, while 3,064 (38%) did not. Veterans with nephrology care were less likely to have severe anemia, more likely to have vascular access, and less likely to die at 1 year (p < .05) than veterans without nephrology care. Among veterans receiving nephrology care, 20% (Medicare-Only) to 25% (VA-Only) had severe anemia. Upon adjusted analyses, VA-Only users were more likely (RR 1.26; 95% CI: 1.04-1.52) than Cross-system or Medicare-Only users to have severe anemia. Among nephrology care recipients, 44% of VA-Only, 51% of Medicare-Only, and 60% of Cross-system users received vascular access. Cross-system users had a greater likelihood (RR 1.15; 95% CI 1.05-1.27) of vascular access while VA-Only users tended to be lower (RR 0.90; 95% CI: 0.81-1.00) than Medicare-Only users. One-year mortality was 30% for VA-Only, 26% for Cross-system, and 32% for Medicare-Only users. In regression analyses, Cross-system users were less likely to die at 1 year on dialysis (RR 0.84) compared with Medicare-Only and VA-Only users (p < .05).
Veterans using both VA and Medicare for predialysis nephrology care had superior dialysis-related health outcomes compared to those using either VA or Medicare alone.
To improve unsatisfactory dialysis-related health outcomes, efforts are needed to understand the disparities among veterans using VA and Medicare for predialysis nephrology care.