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IIR 18-032 – HSR Study

IIR 18-032
Optimizing the value of community care for Veterans with advanced kidney disease
Ann M. O'Hare, MD MA
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: December 2019 - September 2024


The Veterans Health Administration has a long history of providing maintenance dialysis treatment for Veterans with end-stage renal disease (ESRD) in the community under the VA Fee Basis program. Starting Fiscal Year 2015, access to specialized nephrology care in the community became available to the much larger population of Veterans with advanced kidney disease not yet on dialysis under the Veterans Choice Program (VCP) and is expected to continue under a consolidated Community Care program. Like their counterparts on dialysis, Veterans with advanced kidney disease not on dialysis are a high-cost high-needs population for whom access to care, continuity of care and coordination of care are all vitally important in optimizing quality and outcomes. All three metrics are important in building strong relationships between patients and providers, and supporting the kind of iterative cycle of evaluation and re-evaluation and care coordination needed to properly care for these patients Objective: We will use mixed methods to study the impact of the VA’s evolving community care policy on outcomes and costs for Veterans with advanced kidney disease and identify opportunities for program improvement. Because many of the outcomes and care processes relevant to this population are sensitive to continuity and coordination of care, we hypothesize that receipt of VA-financed nephrology care in the community will negatively impact a range of clinical outcomes and care processes relevant to this population and will be more costly than nephrology care provided within the VA. We anticipate that for some groups, the potential harms of care fragmentation and discontinuity may be outweighed by the benefits of more timely receipt of needed care in the community. Because some VA medical centers may be more effective in coordinating care with community providers to mitigate the effects of care fragmentation, we hypothesize that there will be heterogeneity in the effect of VA-financed community care within the population and across VA medical centers that could be informative in improving the process of community referral for this population. Methods: We will use national VA administrative and clinical data to track the impact of VA-financed community care on clinical outcomes, care processes and costs to the VA system among Veterans with advanced kidney disease using an instrumental variable approach (Aim 1). To identify opportunities for improving the value of community referral for this population, we will elicit the perspectives and experiences of Veterans with advanced kidney disease eligible for, or receiving VA-financed community care and their VA and community care providers (Aim 2). Impact: This proposal will directly address three VA HSR&D priority areas (Health Care Systems Change, Healthcare Access and Patient-centered Care, Care Management, and Health Promotion). The work proposed here is extraordinarily timely and policy-relevant given that the VA MISSION Act of 2018 recently passed both the House and the Senate with strong bipartisan support. We anticipate that our work to measure the impact of VA-financed community nephrology care on Veterans with advanced kidney disease will help to identify opportunities for more effective use of agency resources to optimize access, continuity and coordination of care for a high-cost high-needs segment of the Veteran population. To ensure that our work is poised to shape evolving VA policy around provision of community care, the investigators are partnering with the VHA National Program for Kidney Disease and the Office of Community Care

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Journal Articles

  1. Wang V, Zepel L, Diamantidis CJ, Smith VA, Scholle SH, Maciejewski ML. Annual wellness visits and care management before and after dialysis initiation. BMC nephrology. 2021 May 5; 22(1):164. [view]
  2. Diamantidis CJ, Zepel L, Wang V, Smith VA, Hudson Scholle S, Tamayo L, Maciejewski ML. Disparities in Chronic Kidney Disease Progression by Medicare Advantage Enrollees. American Journal of Nephrology. 2021 Dec 7; 52(12):949-957. [view]
  3. O'Hare AM, Butler CR, Laundry RJ, Showalter W, Todd-Stenberg J, Green P, Hebert PL, Wang V, Taylor JS, Van Eijk M, Matthews KL, Crowley ST, Carey E. Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA internal medicine. 2022 Jul 1; 182(7):710-719. [view]
  4. Sloan CE, Coffman CJ, Sanders LL, Maciejewski ML, Lee SD, Hirth RA, Wang V. Trends in Regional Supply of Peritoneal Dialysis in an Era of Health Reform, 2006 to 2013. Medical care research and review : MCRR. 2021 Jun 1; 78(3):281-290. [view]
  5. Hughes JM, Bartle JT, Choate AL, Mahanna EP, Meyer CL, Tucker MC, Wang V, Allen KD, Van Houtven CH, Hastings SN. Walking All over COVID-19: The Rapid Development of , an Innovative Approach to Enhance a Hospital-Based Walking Program during the Pandemic. Geriatrics (Basel, Switzerland). 2021 Nov 10; 6(4). [view]

DRA: Health Systems, Kidney Disorders
DRE: TRL - Applied/Translational, Treatment - Observational
Keywords: Care Coordination
MeSH Terms: None at this time.

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