End stage renal disease (ESRD) is more prevalent among VA users than the general US population and is associated with substantial morbidity, mortality, and VA health care costs. Demand for dialysis treatment for ESRD exceeds VA's limited supply, requiring VA to outsource dialysis care from non-VA providers through the VA Fee Basis program. VA costs for Fee Basis dialysis have been increasing at an astonishing rate with little understanding of its value to VA or its Veterans. This has prompted concerns in VA, particularly because VA exerts little clinical oversight or accountability for outsourced care for its patients. In light of these concerns, VA is exploring new care and payment models to improve quality of care and reduce costs. It remains unclear how dialysis patient outcomes differ between Veterans obtaining dialysis care in various settings.
The objective of this study was to create a national cohort of Veterans with ESRD from 2008 to 2013 using VA and Medicare data sources to understand trends in Veterans' choice of setting for chronic dialysis (Aim 1), to identify patient and VAMC-level characteristics associated with setting for chronic dialysis (Aim 2), and to examine whether all-cause and cause-specific hospitalization and mortality rates vary by setting (Aim 3).
We conducted a retrospective observational cohort study of Veterans with incident ESRD who were enrolled in VA between 2008 and 2013. We used VA and Medicare administrative data to identify Veterans' use of outpatient-based maintenance dialysis services in VA, VA-purchased care (PC), and Medicare programs. VA data sources included information on Veteran enrollment, inpatient and outpatient encounters, and use of VA-PC provided in community settings. Medicare data included Medicare enrollment and claims files and the US Renal Data System (USRDS), a comprehensive national registry of all ESRD patients and providers in the US. We identified all VA-enrolled Veterans initiating outpatient maintenance dialysis in 2008-2011 from the USRDS patient registry and a crosswalk file of Veterans from the Veterans Information Resource Center. Veterans were defined as those who enrolled in, obtained healthcare or compensation or pension benefits from the VA and were thus eligible for VA services. We excluded patients who received a kidney transplant at the time of dialysis initiation; died within the first 90-days or recovered renal function within the first 180 days of dialysis initiation; had an invalid residence zip code or lived outside the US (i.e., Puerto Rico, Guam); had incomplete or lacked timely recording (e.g., within 90-days) of demographic or clinical information at dialysis initiation. We also excluded Veterans who were enrolled in Medicare Advantage or had unknown Medicare status; did not have any VA, VA-PC, or Medicare recorded claims or encounters for outpatient dialysis; and a minority of patients who were hospitalized the entire observed period of follow-up. The final cohort in the dialysis setting analysis included 27,301 Veterans.
In an analysis of Veteran characteristics associated with utilization of maintenance dialysis under VA, VA-PC, Medicare, or mixed settings in the two years following initiation in 2008-2011, we found that Veteran choice of dialysis setting was largely time-invariant and that a majority (67%) of Veterans obtained dialysis via Medicare. Notably, nearly three times as many Veterans were obtaining community-based dialysis purchased by VA than were obtaining it from VA facilities, so VA has been choosing to buy in its "make or buy" decision for dialysis care for quite some time. There was also significant regional variation in use of dialysis via Fee Basis, Medicare, and multiple settings. In multinomial logistic regression, we found that demographic, clinical, and access factors were all significant predictors of dialysis setting (p <0.0001). Distance from VA dialysis, exemption from VA copayment, and region were the most important factors in Veterans' financing and setting for dialysis, suggesting that this choice was more driven by access factors than clinical need or demographic factors. In unadjusted comparison of all-cause hospitalization across the four dialysis settings, 62-72% of Veterans in all four groups were hospitalized in the year prior to dialysis initiation and hospitalization rates subsequently declined over the next two years. In adjusted analyses, there were no differences in length of stay over the 2 years following dialysis initiation. In survival analyses, Veterans obtaining dialysis from two or more of 3 settings (VA, VA Purchased Care, Medicare) had the highest survival rate, followed by Veterans obtaining care by VA.
Results from this study can inform VA efforts to improve the quality and efficiency of dialysis care to a growing population of Veterans with end-stage renal disease. The majority of Veterans used Medicare benefits for dialysis care during the study period, but the VA deftly met increasing Veteran demand for dialysis through its in-house service and procurement of non-VA services in communities. Operating under a fixed, global budget VA is limited in its ability to meet rising demand without budget increases or policy intervention. For example, policies to allocate care coordination resources or the development of protocols or decision tools for determining placement and timing for optimal outcomes may need to be established. As VA expands Veteran access to community care via the Veteran Choice Program, risk-adjusted outpatient dialysis payments and quality may also be a model for considering community care for healthier Veterans. Findings have been disseminated to the VA Renal Field Advisory Board via Dr. Susan Crowley and VISN 6 Office, which is spearheading VA's national effort (on a demonstration basis) for freestanding VA dialysis facilities.
- Wang V, Coffman CJ, Stechuchak KM, Berkowitz TSZ, Hebert PL, Edelman D, O'Hare AM, Crowley ST, Weidenbacher HJ, Maciejewski ML. Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings. Journal of the American Society of Nephrology : JASN. 2019 Jan 1; 30(1):159-168.
- Wang V, Coffman CJ, Stechuchak KM, Berkowitz TSZ, Hebert PL, Edelman D, O'Hare AM, Weidenbacher HJ, Maciejewski ML. Comparative Assessment of Utilization and Hospital Outcomes of Veterans Receiving VA and Non-VA Outpatient Dialysis. Health services research. 2018 Dec 1; 53 Suppl 3:5309-5330.
- Wang V, Diamantidis CJ, Wylie J, Greer RC. Minding the gap and overlap: a literature review of fragmentation of primary care for chronic dialysis patients. BMC nephrology. 2017 Aug 29; 18(1):274.
- Wang V, Coffman CJ, O'Hare AM, Maciejewski ML. Authors' Reply. [Letter to the Editor]. Journal of the American Society of Nephrology : JASN. 2019 Jul 1; 30(7):1338-1339.
Health Systems, Diabetes and Related Disorders
Treatment - Comparative Effectiveness
Cost-Effectiveness, Diabetes, Outcomes - Patient, Patient Preferences, Utilization