- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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