With more than 27,000 Veterans receiving treatment for end-stage renal disease (ESRD) annually, the decision to initiate maintenance dialysis for older Veterans with ESRD affords one of the greatest opportunities to improve value in specialty care. The burden of ESRD among Veterans is projected to double over the next decade, largely due to higher incidence and treatment rates of end-stage renal disease among Veterans over the age of 75. Treatment of ESRD with maintenance dialysis is resource intensive and outcomes are often poor among older adults with serious comorbidity. Similar to other intensive procedures performed near the end of life, there are wide regional variations in the utilization of dialysis among older adults, suggesting that intensity of treatment for end-stage renal disease is determined by practice style or the supply of medical resources rather than the likelihood of benefit.
The objectives of this study are to: (a) identify factors associated with utilization of maintenance dialysis among older Veterans with ESRD; (b) characterize the context of decision-making when treatment decisions are discordant with evaluated need; and (c) compare survival and healthcare utilization for older Veterans who initiate maintenance dialysis to those who receive conservative management.
To achieve these objectives, we are assembling a national cohort of Veterans (~39,000 Veterans) approaching ESRD using VA claims data, laboratory records, and data from the US Renal Data System. Our conceptual model is based on the work of Andersen and Newman that conceptualizes dialysis utilization as a complex interplay of predisposing patient characteristics, enabling resources, evaluated need, and characteristics of the health care system. Our focus is on enabling resources and characteristics of the health care system, since these aspects are modifiable and have implications for how VA allocates specialty care resources. To characterize the context of decision-making when treatment decisions are discordant with evaluated need, we are developing a chart abstraction protocol that will be used to obtain a more complete understanding of the relationship between treatment and patient/family preferences for care. In addition to patient preferences, barriers to shared decision-making are likely to play a role in these circumstances.
1. The benefits of maintenance dialysis for older adults with end-stage renal disease (ESRD) are uncertain. Whether the setting of pre-ESRD nephrology care influences initiation of dialysis and mortality is not known. We compared initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-ESRD nephrology care in fee-for-service Medicare vs the Department of Veterans Affairs (VA). We identified 11 215 veterans aged 67 years or older with incident kidney failure between January 1, 2008, and December 31, 2011. Patients who received pre-ESRD nephrology care in Medicare were more likely to undergo dialysis compared with patients who received pre-ESRD nephrology care in VA (82% vs 53%; adjusted risk difference, 28 percentage points; 95% CI, 26-30 percentage points). Differences in dialysis initiation between Medicare and VA were more pronounced among patients aged 80 years or older and patients with dementia or metastatic cancer, and less pronounced among patients with paralysis (P < .05 for interaction). Two-year mortality was higher for patients who received pre-ESRD care in Medicare compared with VA (53% vs 44%; adjusted risk difference, 5 percentage points; 95% CI, 3-7 percentage points). The findings were similar in a propensity-matched analysis. Veterans who receive pre-ESRD nephrology care in Medicare receive dialysis more often yet are also more likely to die within 2 years compared with those in VA. The VA's integrated health care system and financing appear to favor lower-intensity treatment for kidney failure in older patients without a concomitant increase in mortality.
2. Appropriate patient selection and optimal timing of dialysis initiation among older adults with advanced CKD are uncertain. We determined the association between dialysis versus medical management and survival at different ages and levels of kidney function. We assembled a nationally representative 20% sample of United States veterans with eGFR<30 ml/min per 1.73 m2 between 2005 and 2010 (n=73,349), with follow-up through 2012. We used an extended Cox model to determine associations among the time-varying exposures, age (<65, 65-74, 75-84, and 85 years), eGFR (<6, 6-<9, 9-<12, 12-<15, and 15-<29 ml/min per 1.73 m2), and provision of dialysis, and survival. Over the mean follow-up of 3.4±2.2 years, 15% of patients started dialysis and 52% died. The eGFR at which dialysis, compared with medical management, associated with lower mortality varied by age (P<0.001). For patients aged <65, 65-74, 75-84, and 85 years, dialysis associated with lower mortality for those with eGFR not exceeding 6-<9, <6, 9-<12, and 9-<12 ml/min per 1.73 m2, respectively. Dialysis initiation at eGFR<6 ml/min per 1.73 m2 associated with a higher median life expectancy of 26, 25, and 19 months for patients aged 65, 75, and 85 years, respectively. When dialysis was initiated at eGFR 9-<12 ml/min per 1.73 m2, the estimated difference in median life expectancy was <1 year for these patients. Provision of dialysis at higher levels of kidney function may extend survival for some older patients.
Findings from this study to date have several important implications for VA policymakers and patients.
First, VA's integrated health care system and financing appear to favor lower-intensity treatment for kidney failure in older patients without a increase in mortality. The findings also suggest there may be unintended consequences of expanding access to non-VA care if care is not coordinated across health care systems.
Second, our findings describing the predicted benefit of dialysis at different ages and levels of kidney function can support shared decision making for dialysis.
- Bradshaw CL, Gale RC, Chettiar A, Ghaus SJ, Thomas IC, Fung E, Lorenz K, Asch SM, Anand S, Kurella Tamura M. Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2020 May 1; 75(5):744-752.
- Kurella Tamura M, Desai M, Kapphahn KI, Thomas IC, Asch SM, Chertow GM. Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD. Journal of the American Society of Nephrology : JASN. 2018 Aug 1; 29(8):2169-2177.
- Kurella Tamura M, Thomas IC, Montez-Rath ME, Kapphahn K, Desai M, Gale RC, Asch SM. Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs. JAMA internal medicine. 2018 May 1; 178(5):657-664.