Stroupe KT (Center for Management of Complex Chronic Care (CMC3)), Fischer MJ
(CMC3), Kaufman JS
(Boston VAMC), O'Hare AM
(Seattle VAMC), Browning MM
(CMC3), Huo Z
(CMC3), Hynes DM
Patients with end-stage renal disease (ESRD) require chronic hemodialysis to replace lost kidney function. Nephrology care before dialysis initiation (i.e., the pre-dialysis period) facilitates preparation for dialysis and is associated with better health outcomes after dialysis initiation. However, less is known about the impact of pre-dialysis nephrology care on costs after hemodialysis initiation. We examined the association of pre-dialysis nephrology care with healthcare costs and outcomes after hemodialysis initiation.
We conducted a retrospective cross-sectional analysis of veterans 66 years or older who initiated chronic dialysis in 2000-2001 and were eligible for both VA and Medicare coverage during the one-year pre-dialysis period. We used both VA and Medicare data sources to measure the association of pre-dialysis nephrology care with hospitalizations, total healthcare costs, and mortality following hemodialysis initiation. We performed multivariable logistic regression to examine hospitalization and mortality and multivariable generalized linear models (GLM) to examine costs, controlling for demographics, disease characteristics, and pre-dialysis healthcare costs.
Among the 8,715 veterans in our cohort, 3,215 (37%) began chronic dialysis without prior outpatient nephrologist visits under Medicare or within VA. Of those with pre-dialysis nephrology care, 2,080 were low-intensity (< 3 nephrology visits), 1,444 were medium-intensity (3 to 6 visits), and 1,976 were high-intensity (> 6 visits) users. Pre-dialysis nephrology care was associated with decreased hospitalization relative to no nephrology care: odds ratio (OR) = 0.77 for low-intensity (P = 0.02), OR = 0.55 for medium-intensity (P < 0.001), and OR = 0.35 for high-intensity (P < 0.001) users during six months after hemodialysis initiation. Total costs, adjusting for characteristics in the GLMs, were $60,811 for veterans without nephrology care, $52,628 for low-intensity, $46,225 for medium-intensity, and $42,262 for high-intensity users (P < 0.0001) during six months after hemodialysis initiation. Multivariable analysis also indicated pre-dialysis nephrology care was associated with lower mortality after hemodialysis initiation.
Receipt of pre-dialysis nephrology care was associated with lower rates of hospitalization and death and lower costs after chronic hemodialysis initiation.
Efforts to increase pre-dialysis nephrology care of veterans in the pre-dialysis period may not only improve patient outcomes but also has the potential to lower healthcare costs.