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Compared to Medicare, Veterans with VA-Financed Care are More Likely to Receive Dialysis and Hospice for Kidney Disease
In contrast to Medicare, VA is committed to ensuring that Veterans have access to hospice services regardless of whether they are still receiving disease-modifying treatments, such as dialysis for end-stage kidney disease (ESKD). This study sought to answer the question: Does the frequency of concurrent hospice and dialysis (“concurrent care”) among Veterans with ESKD vary by hospice payer? Findings showed that rates of concurrent care were substantially higher among Veterans receiving VA-financed, compared with Medicare-financed, hospice services. The proportion of Veterans receiving concurrent care was lower for those receiving Medicare-financed hospice (25%) than for those receiving VA-financed hospice, either under VA Community Care (42%) or in VA inpatient hospice (55%). Regardless of hospice payer, VA paid for the majority (87%) of dialysis treatments after Veterans were enrolled in hospice. Veterans who received concurrent care had a median hospice length-of-stay of 43 days, compared with 4 days for those who did not. Findings suggest that there is probably a substantial unmet need for concurrent care among the large majority of Veterans with ESKD receiving hospice services under Medicare.
Date: October 7, 2022
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Traumatic Brain Injury May Be a Potentially Novel Risk Factor for Cardiovascular Disease in Veterans
This study sought to determine the association between TBI and subsequent cardiovascular disease (CVD) in post-9/11 era Veterans. Findings showed that post-9/11 Veterans with mild TBI, moderate to severe TBI, and penetrating TBI were more likely to develop CVD compared to Veterans without TBI. Although the risk was highest shortly after injury, TBI remained significantly associated with CVD for years after the initial injury. All TBI categories increased the risk of stroke, coronary artery disease, and peripheral artery disease. Mild and moderate to severe TBI categories were also associated with an increased risk of CVD mortality. Veterans with TBI were more likely to have a history of smoking, substance use disorder, obesity, obstructive sleep apnea, insomnia, PTSD, depression, and anxiety. Conversely, hyperlipidemia, kidney disease, hypertension, and diabetes were more common in Veterans without TBI.
Date: September 6, 2022
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Challenges and Strain on VA System Associated with VA-Funded Community Care for Veterans with Advanced Kidney Disease
This study sought to further the understanding of the internal challenges of cross-system healthcare use to the VA healthcare system and enrolled Veterans. Three dominant themes pertaining to VA-financed community care were identified. Themes described VA as mothership, the hidden work of Veterans, and strain on the VA system. ‘VA as mothership’ describes extensive care coordination by VA staff members and clinicians to facilitate care outside VA – and the tendency of Veterans and their non-VA clinicians to rely on VA to fill gaps in this care. ‘Hidden work of Veterans’ refers to the efforts of Veterans and family members to navigate the referral process – and to serve as intermediaries between VA and non-VA clinicians. ‘Strain on the VA system’ refers to the challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes, particularly for social workers who often served as a point-of-contact for Veterans. Overall, 607 (61%) members of the study cohort had at least one active or paid claim for VA-financed non-VA care during follow-up.
Date: May 16, 2022
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Black Veterans with Chronic Kidney Disease Experience Racism in the Healthcare Setting, Resulting in Stress and Distrust
This study investigated the healthcare experiences of Black Veterans with chronic kidney disease to assess any discrimination faced by this vulnerable population. Findings showed that these Veterans experienced racism in the healthcare setting resulting in physical and emotional stress and distrust in the healthcare system. Some Veterans also expressed a need to be hypervigilant during the clinical encounter. Veteran comments included: “…it seemed like everything I asked her about, ‘Oh, don’t worry about that. Don’t worry.’ I said, “What do you mean don’t worry about that? I’m concerned about it.” ‘But I tell you when you need to worry.’ “So, I got rid of her.” (patient switched to a different provider) “I just watch how… the interaction with other patients that are White. They may spend time with them, talking with them, this or that… less time with me or the other African Americans that are in the clinic.” When encountering racism, Veterans described both negative (e.g., hypervigilance) and positive (e.g., faith) coping strategies. Talking and sharing stressful events with family was also a major source of support for respondents.
Date: May 12, 2022
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Social and Behavioral Risk Factors Are Not Associated with Higher Mortality among VA Patients with COVID-19
This study sought to determine if social and behavioral risk factors were associated with mortality from COVID-19 among Veterans, and whether the association was modified by race/ethnicity. Findings showed that despite relatively high levels of social and behavioral risk among Veterans in this study, no association with mortality from COVID-19 was found. Housing problems, financial hardship, current tobacco, alcohol, and substance use did not have statistically significant associations with mortality. Analyses by race/ethnicity did not find associations between mortality and these risk factors. Predictors of mortality in this study were consistent with other studies, including older age, Asian and American Indian or Alaska Native race, and certain comorbid conditions, such as diabetes, chronic kidney disease, dementia, and cirrhosis or hepatitis. This study highlights how integrated health systems such as VA can transcend social vulnerabilities and serve as models of support services for COVID-affected households and at-risk populations.
Date: June 9, 2021
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VA Researchers Develop Model to Estimate Risk of COVID-19 Related Deaths among Veterans for Use in Prioritizing Vaccine
This study sought to develop a model to estimate the risk of COVID-19 related death in the general population to aid vaccination prioritization. In estimating the risk, COVIDVax (the model developed) used the following 10 patient characteristics: sex, age, race, ethnicity, body mass index (BMI), Charlson Comorbidity Index (CCI), diabetes, chronic kidney disease, congestive heart failure, and the Care Assessment Need (CAN) score. Using COVIDVax to prioritize vaccination was estimated to prevent 64% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than prioritizing vaccination based on age (46%) or the CDC phases of vaccine allocation (41%). Even under conditions when vaccine supply is no longer limited, the model can help target individuals who might not yet be vaccinated but are at highest risk from COVID.
Date: April 6, 2021
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Veterans Receiving VA-Only Post-Kidney Transplant Care Had Lower Five-Year Mortality Compared to Non-VA Transplant Care
This study sought to characterize where Veterans dually enrolled in VA and Medicare underwent kidney transplantation and received post-transplant care – and to evaluate the association of post-transplant care source with longer-term mortality. Findings showed that in the first year following transplantation, 752 Veterans (12%) received post-transplant care in VA only, 2,092 (34%) through Medicare only, and 3,362 (54%) through both VA and Medicare. Veterans who received VA-only post-transplant care had the lowest 5-year mortality compared to those receiving such care via Medicare or both VA and Medicare. Over 5 years of follow-up, 1,053 Veterans (17%) died overall. Patients who received Medicare-only post-transplant care had a higher 5-year mortality rate compared with VA-only patients (20% v. 11%), as did dual care patients (16% v. 11%). There also was lower 30-day mortality among those transplanted within VA compared to outside VA (<1% v. 1.3%). The need for dialysis at one year was lower in Veterans who received VA-only post-transplant care than Medicare only (2% v. 3%) and dual care (2% v. 4%). These findings can inform patient decisions regarding the preferred venue of care following kidney transplantation and highlight the critical importance of monitoring patient outcomes as VA expands options for care in the community via the MISSION Act and other healthcare legislation.
Date: March 8, 2021
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Older Age Strongest Risk Factor Associated with Mechanical Ventilation and Death among Veterans with COVID-19
This study sought to identify risk factors associated with hospitalization, mechanical ventilation, and death among patients with COVID-19 infection. Findings showed that Veterans who were COVID-positive were more likely to be Black (42% vs 25%), obese (45% vs 40%), and to live in states with a high burden of COVID-19 compared to Veterans who tested negative. Veterans who tested positive for COVID-19 had a 4.2-fold risk of mechanical ventilation and a 4.4-fold risk of death compared with Veterans who tested negative. Most COVID-19 deaths among Veterans in this study were attributed to age 50 and older (64%), male sex (12%), and greater comorbidity burden (11%). Many factors previously reported to be associated with mortality in smaller studies were not confirmed, including Black race, Hispanic ethnicity, COPD, hypertension, and smoking. Other risk factors for mortality among Veterans with COVID-19 included select pre-existing comorbid conditions, such as heart failure, chronic kidney disease, and cirrhosis.
Date: September 23, 2020
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VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival
This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Findings showed that VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising access to care or survival. Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%). Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly.
Date: September 22, 2020
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VA’s Lower Intensity Treatment of Kidney Failure – Compared to Medicare – Does Not Result in Associated Increased Mortality
This study compared the initiation of dialysis and mortality among Veterans ages 67 and older with incident kidney failure who received pre-end-stage renal disease (ESRD) care in fee-for-service Medicare vs. VA between January 2008 and December 2011. Findings showed that Veterans who received pre-ESRD nephrology care in Medicare received dialysis more often than Veterans who received VA care (82% vs. 53%), yet Medicare patients were more likely to die within two years compared with VA patients (54% vs 43%). Differences in the frequency of dialysis treatment between Medicare and VA were larger among Veterans aged 80 years or older and among Veterans with dementia or metastatic cancer – subgroups that are less likely to realize a survival benefit from dialysis. Results suggest that the VA healthcare system favors lower intensity treatment of kidney failure without an associated increase in mortality.
Date: April 9, 2018
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Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare
To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury.
Date: March 1, 2018
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VA National Transplant System Shows No Racial/Ethnic Disparities in Evaluating Veterans for Kidney Transplant
This study examined VA patients of diverse racial/ethnic backgrounds with end-stage kidney disease (ESKD) who underwent the evaluation process for kidney transplantation (KT). Findings showed that in comparing African American Veterans with white Veterans and other minority Veterans, the VA National Transplant System did not exhibit the racial/ethnic disparities in evaluation for kidney transplant that have been found in non-VA transplant centers. Moreover, VA kidney transplant centers are successfully bringing ESKD patients through the evaluation process without race disparities at a time when non-VA transplant centers are unable to do so, while achieving a median time to complete evaluation similar to other published rates in non-VA settings.
Date: August 1, 2016
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Inpatient Conditions Associated with Increased Risk for Recurrent Acute Kidney Injury among Veterans
This study sought to identify clinical risk factors for recurrent acute kidney injury (AKI) that were present during the index hospitalization for AKI. Findings showed that, in addition to known demographic and comorbid risk factors for AKI (i.e., older age, diabetes, dementia), Veterans at highest risk for hospitalization with recurrent AKI were those whose index AKI hospitalization included congestive heart failure as a primary diagnosis, decompensated advanced liver disease, cancer with or without chemotherapy, acute coronary syndrome, and intravascular volume depletion. Of the Veterans in this cohort, 49% were hospitalized at least once during the follow-up period, and 25% were hospitalized with recurrent AKI within 12 months of discharge. Median time to recurrent AKI was 64 days. The one-year mortality from time of discharge was 23%, and approximately 40% of Veterans who died were re-hospitalized with recurrent AKI before death.
Date: August 11, 2015
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Under-utilization of Cardiac Rehabilitation for Veterans Hospitalized for Ischemic Heart Disease
This study sought to determine: 1) the proportion of Veterans with ischemic heart disease (IHD) who participate in cardiac rehabilitation (CR); 2) whether the presence of an onsite CR program was associated with greater participation; and 3) patient characteristics associated with participation. Findings showed that only 8% of the Veterans in this study who had been hospitalized for MI, PCI, or CABG participated in one or more sessions of outpatient cardiac rehabilitation. Overall, Veterans were more likely to participate in CR if they had been hospitalized at a VA facility with an onsite CR program versus without one (11% vs. 7%). However, participation was extremely low regardless of the presence or absence of an onsite program. Characteristics associated with greater participation in CR included: younger age, being married, higher BMI, living closer to a VA facility, hyperlipidemia, absence of heart failure, absence of chronic kidney disease, and hospitalization for CABG (vs. PCI or MI). After controlling for these variables, the presence of an onsite CR program was associated with 75% greater odds of attending a CR program.
Date: August 18, 2014
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Relationship between Perceived Racial Discrimination and Wait Times for Kidney Transplant
Compared to whites, African Americans took significantly longer to get accepted for transplant.
There were also significant racial differences on several cultural factors in patients as they began the evaluation process for kidney transplantation. Compared to white patients, African Americans reported experiencing more discrimination in healthcare, more perceptions of racism in healthcare, higher medical mistrust, and more religious objections to living donor kidney transplantation. Comorbidity, dialysis status, and availability of potential living donors were not associated with length of time to be accepted for kidney transplant. Thus, medical factors alone did not explain racial disparities. In analyses to identify which factors predicted racial disparities, the authors found that perceived discrimination in healthcare, less transplant knowledge, more religious objection to transplantation, and lower income explained the racial disparities observed in the time it took to be accepted for transplant. Moreover, after adjusting for demographics, psychosocial, and cultural factors, the association of race with longer time for listing for transplant was no longer significant. Authors suggest these findings indicate that perceived discrimination in healthcare can be as much of a risk factor as race, income, or low transplant knowledge.
Date: February 27, 2012
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Study Compares Effectiveness of Oral Anti-diabetic Drugs on Kidney Function for Veterans with Type 2 Diabetes
Among Veterans with type 2 diabetes, initiation of sulfonylureas compared to metformin was associated with an increased risk of clinically significant decline in kidney function, diagnosis of ESRD, or death. Compared to metformin, the use of rosiglitazone was not significantly associated with any outcomes. Compared to sulfonylureas, the use of rosiglitazone was associated with a decreased risk for all three outcomes. Authors suggest that these findings support the current recommendations of metformin as first-line therapy for patients with type 2 diabetes who are in earlier stages of kidney disease.
Date: February 1, 2012
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Low Rate of Referral for Outpatient Nephrology Consultation for Veterans Hospitalized with Acute Kidney Injury
This study examined the likelihood of nephrology referral among survivors of acute kidney injury (AKI) at risk for subsequent decline in kidney function. Findings showed that the majority of Veterans (56%) had persistent CKD (Stage III or IV) one year following their acute event. Consistent with non-VA cohorts, there was a low rate of outpatient referral for kidney specialist care among Veterans hospitalized with acute kidney injury. The cumulative incidence of nephrology referral before death, dialysis, or improvement in kidney function was 8.5%.
Date: December 8, 2011
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Hypertension Care Management Program Provided by Clinical Pharmacists Reduces Blood Pressure among Veterans
This study evaluated the effectiveness of a hypertensive care management program provided by clinical pharmacists in collaboration with primary care physicians within four VA primary care teams at one urban Midwest VAMC. Findings show that Veterans referred to the hypertension care management program provided by VA clinical pharmacists had a significant reduction in blood pressure, and most met their BP treatment goals. Overall, the change in mean systolic BP at the final visit was –11.2 mm Hg from the initial visit, whereas the change in mean diastolic BP at the final visit was –4.6 mm Hg from the initial visit. By the final visit, 75% of Veterans had reached their BP treatment goals, which was 99.5% of the Veterans who completed the program. For Veterans with diabetes or chronic kidney disease (CKD), both systolic and diastolic BP measurements were significantly reduced from the initial pharmacist visit to the final pharmacist visit. Approximately 60% of all Veterans in the program with diabetes and 56% of those with CKD reached their BP goals.
Date: January 1, 2011
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Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
Date: February 1, 2010
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Panel Reaches Consensus on Oral Dosing for Primarily Renally Cleared Medications in Older Adults
Chronic kidney disease (CKD) is a growing public health problem that disproportionately affects older adults. Medications are the most frequently used therapy for the management of CKD-related problems in older adults, but they are often prescribed in inappropriate doses. This study sought to establish consensus dosing guidelines for primarily renally cleared oral medications commonly taken by older adults with renal insufficiency. An expert panel was able to reach consensus agreement on 18 oral medications that are primarily renally cleared, including anti-infectives and central nervous system medications.
Date: February 1, 2009
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Contrast-Induced Acute Kidney Injury (CIAKI) Following Computed Tomography
Clinically significant CIAKI following non-emergent computed tomography is very uncommon among outpatients with mild kidney disease. CIAKI was not associated with need for post-procedure dialysis, hospital admission, or 30-day mortality.
Date: September 1, 2008
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