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Pre-planning for Initiation of Dialysis at VA Medical Centers: Implications for Quality of Care

Stroupe KT, Hynes DM, Colin PM. Pre-planning for Initiation of Dialysis at VA Medical Centers: Implications for Quality of Care. Paper presented at: VA HSR&D National Meeting; 2002 Feb 1; Washington, DC.

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ObjectivesDialysis patients have substantial healthcare use, costing VA over $60 million/year for hemodialysis alone. Another substantial cost for hemodialysis patients is morbidity due to failed vascular access. Guidelines recommend a pre-dialysis planning period to establish permanent vascular access (PVA) with either native fistula or graft. Pre-dialysis planning is needed because PVA takes time to mature before use. Hospitalization for initial dialysis may reflect failure to establish PVA. We determined the extent VA hemodialysis patients received PVA placement pre-dialysis and described the initial dialysis session.MethodsUsing VA's National Patient Care Database, we identified patients who initiated dialysis in FY2000 and had no VA dialysis in FY1999. We examined how many patients had pre-dialysis PVA placement. We examined the initial dialysis session to determine how many patients received initial dialysis as inpatients, how many used chronic dialysis after initiating dialysis, and how many died during the initial hospitalization for dialysis. We defined chronic dialysis as > = 2 dialysis sessions/week for eight weeks after dialysis initiation.Results VA's pre-planning for dialysis was low. Of the 281 chronic dialysis patients, only 19% had initial PVA placement > 6 months before dialysis initiation, and only 23% had PVA placement 1-6 months pre-dialysis. Among acute dialysis patients 28% had their first vascular access placement during the first dialysis session, and 8% had vascular access placement pre-dialysis. Dialysis was initiated in an inpatient setting among 36% of chronic and 73% of acute dialysis patients, and 25% of acute dialysis patients died during this initial hospitalization.Conclusions Our results indicated that over half of VA patients do not have pre-dialysis PVA placement. Since morbidity associated with failed vascular access is a leading cause of dialysis patients' hospitalizations, inadequate pre-dialysis PVA placement may result in poor quality of care and excessive treatment costs.

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