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Stroupe KT, O'Hare AM, Fischer MJ, Kaufman J, Browning MM, Huo Z, Hynes DM. Guideline-Recommended Care for Veterans with End Stage Renal Disease: Impact of System of Care. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
Objectives: Patients with end stage renal disease (ESRD) require chronic hemodialysis to replace lost kidney function, costing over $50,000 annually. Among patients initiating chronic hemodialysis, using a temporary catheter rather than a more permanent form of vascular access (PVA) is associated with excess morbidity, mortality, hospitalization, and cost. To minimize catheter use, most clinical practice guidelines recommend timely placement of PVA before dialysis initiation. The role of the healthcare system (i.e., VA vs. non-VA) in determining whether patients receive predialysis PVA has not been studied. We examined the impact of healthcare system exposure on the likelihood of receiving guideline-recommended predialysis PVA. Methods: We conducted a retrospective cross-sectional analysis of veterans eligible for both VA and Medicare coverage (age > = 66 years) at least one year before initiating hemodialysis in calendar year 2000 to 2001. Based on their overall outpatient predialysis care, we classified these veterans by healthcare system use: VA-only, Medicare-only, or cross-system (VA + Medicare) use. We used multivariable regression analyses to examine the association of healthcare system use with the probability of any predialysis PVA placement, controlling for demographic, geographic, and disease characteristics. Results: Among the 8,636 veterans in our study, 1,348 (16%) were VA-only users, 3,368 (39%) were Medicare-only users, and 3,920 (45%) were cross-system users. VA-only users were more likely to be African-American, live closer to a VA, and have lower health-risk scores. Less than 50% of veterans had a predialysis PVA: 34% of VA-only users, 44% of Medicare-only users, and 44% of cross-system users (P < 0.001). Multivariable analyses revealed that Medicare-only and cross-system users were over 1.3 times more likely than VA-only users to receive a predialysis PVA (Medicare-only users: risk ratio [RR]: 1.37, 95% CI: 1.26 to 1.39; cross-system users: RR: 1.34, 95% CI: 1.23 to 1.46). Implications: The majority of veterans who initiated chronic dialysis during the study period had not received a PVA beforehand. Veterans using VA outpatient services only were substantially less likely to receive PVA placement than Medicare-only and cross-system users. Impacts: Efforts are needed to increase rates of predialysis PVA placement among patients beginning hemodialysis, particularly those receiving all outpatient care within VA.
