Veterans with end-stage renal disease (ESRD) require chronic dialysis or kidney transplantation to replace lost kidney function, requiring healthcare resources costing over $50,000 per patient annually. Prior to development of ESRD, many patients experience a gradual decline in kidney function. The National Kidney Foundation has developed guidelines for pre-dialysis care, including recommendations for nephrologist referral, vascular access placement, and anemia management. The availability of Medicare coverage may affect pre-dialysis care. Dual VA/Medicare eligibility might improve access to pre-dialysis care but may also lead to fragmented care. Thus, it is important to examine the impact of healthcare system used (i.e., VA only, Medicare only, or both) on the quality of pre-dialysis care and the subsequent impact on healthcare costs after dialysis initiation.
In this study we (1) examined the timeliness of nephrologist visits, permanent vascular access placement, and erythropoietic stimulating agent (ESA) administration for anemia management prior to hemodialysis initiation among veterans (VA-only outpatient users, Medicare-only outpatient users, or cross-system outpatient users of both VA and Medicare-covered services); (2) described clinical parameters (i.e., hemoglobin values) of veterans at hemodialysis initiation by health system use groups; (3) examined healthcare use and costs at hemodialysis initiation and for 6 months of follow-up by healthcare system use; and (4) examined the association of timely nephrologist visit and vascular access placement with clinical parameters, healthcare utilization, and cost after hemodialysis initiation.
Using data from the US Renal Data System (USRDS), a national patient registry, we identified all VA users or potential users (i.e., veterans enrolled in the Veterans Health Administration or receiving pension and compenstation from VA) who initiated chronic hemodialysis in 2000-2001 and were > 66 years of age at the time of this initiation (to ensure that veterans were Medicare eligible during the 1-year period before hemodialysis initiation). We used bivariate and multivariable analyses to examine the effect of healthcare system use during the 1-year period before hemodialysis initiation on quality of pre-dialysis care and to examine the impact of healthcare system used and pre-dialysis care on costs at hemodialysis initiation.
We identified from USRDS a cohort of 8,715 veterans available for our analyses who initiated hemodialysis in 2000 or 2001 and were > 66 years old at hemodialysis initiation: 1433 VA-only (16%), 3911 cross-system (45%), and 3371 Medicare-only (39%) users. The proportion of veterans receiving any nephrologist care in the pre-dialysis period was 58% for Medicare only and 66% for VA only and cross-system users (P < 0.0001). Less than 50% of veterans had a pre-dialysis permanent vascular access: 25% of VA-only, 26% of Medicare-only, and 30% of cross-system users (P < 0.001). Over 60% of veterans had low hemoglobin (i.e., < 11 gm/dL) at hemodialysis initiation: 73% of VA only, 68% of cross system, and 67% of Medicare only users. Among the 5940 veterans with low hemoglobin, 34% of VA only, 36% of cross system, and 36% of Medicare only users received an ESA for anemia. During the first 6 months after hemodialysis initiation, average total (unadjusted) healthcare costs differed by healthcare systems used in the 1-year pre-dialysis period: $64,473+$51,794 SD for VA only outpatient users, $56,134+$41,862 SD for cross-system outpatient users, and $54,047+$38,636 for Medicare-only outpatient users (P < 0.0001). Veterans who had received nephrologist-provided care in the pre-dialysis period had lower mean (unadjusted) total costs over 6 months after hemodialysis initiation than patients without nephrologist care ($51,812 vs $65,057, P < 0.0001). Veterans with a permanent vascular access had lower mean (unadjusted) total costs over this 6-month period ($47,286 vs $62,755, P<0.0001).
This study examined key aspects of pre-dialysis care (nephrologist care, permanent vascular access placement, and anemia management) and healthcare costs after hemodialysis initiation. Our findings highlight aspects of pre-dialysis care for patients with chronic kidney disease where policymakers might target efforts for improvement to improve care for this costly patient population.
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- Fischer MJ, Stroupe KT, Kaufman JS, O'Hare AM, Browning MM, Huo Z, Hynes DM. Predialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services. The American journal of managed care. 2010 Feb 1; 16(2):e57-66.
- 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.
- Stroupe KT, Fischer M, Hynes DM, O'Hare AM, Browning M, Sohn M, Huo Z. Predialysis care across healthcare systems among patients with chronic kidney disease. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
- Stroupe KT, Fischer MJ, Hynes DM, O'Hare AM, Browning M, Sohn MW, Huo Z, Kauffman JS. Predialysis Nephrology Care among Veterans and Non-Veterans with Chronic Kidney Disease. Presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
- Fischer MJ, Wick G, Stroupe KT, Hynes DM, Browning M, Huo Z, Kaufman J. Chronic Kidney Disease Is Significantly Underrecognized Among VA Primary Care Users. Poster session presented at: National Kidney Foundation Clinical Spring Meeting; 2008 Apr 3; Dallas, TX.
- Fischer MJ, Stroupe KT, Kaufman J, O'Hare AM, Browning M, Huo Z, Hynes DM. Venue of Predialysis Nephrology Care and Dialysis-Related Health Outcomes. Paper presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD.
- Fischer MJ, Stroupe KT, Hynes DM, Browning M, Huo Z, O'Hare A, Kaufman J. Validation of Predialysis Erythropoietin Administration on the End-Stage Renal Disease Medical Evidence Report. Poster session presented at: American Society of Nephrology Renal Week Annual Meeting; 2007 Nov 2; San Francisco, CA.
- Stroupe KT, O'Hare AM, Fischer MJ, Kaufman J, Browning MM, Huo Z, Hynes DM. Guideline-Recommended Care for Veterans with End Stage Renal Disease: Impact of System of Care. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
- Stroupe KT, Hynes DM, Browning MM, Kaufman JS, Peterman A, Huo Z. VA Versus Private-Sector Coverage of Hemodialysis Care for Veterans. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.
Aging, Older Veterans' Health and Care, Health Systems
Epidemiology, Treatment - Observational
Chronic disease (other & unspecified), Utilization patterns, VA/non-VA comparisons