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Original Investigation
May 2018

Dialysis Initiation and Mortality Among Older Veterans With Kidney Failure Treated in Medicare vs the Department of Veterans Affairs

Author Affiliations
  • 1Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 2Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
  • 3Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California
  • 4Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 5Division of General Medicine, Stanford School of Medicine, Palo Alto, California
JAMA Intern Med. 2018;178(5):657-8. doi:10.1001/jamainternmed.2018.0411
Key Points

Question  Among veterans with kidney failure, is receipt of nephrology care in Medicare vs the Veterans Affairs health care system associated with more frequent initiation of dialysis or higher overall survival?

Findings  In this cohort study of 11 215 older veterans with kidney failure, receipt of nephrology care in Medicare was associated with a 28 percentage point higher frequency of dialysis initiation, and a 5 percentage point higher frequency of death.

Meaning  The Veterans Affairs health care system appears to favor lower intensity treatment of kidney failure without an associated increase in mortality.

Abstract

Importance  The benefits of maintenance dialysis for older adults with end-stage renal disease (ESRD) are uncertain. Whether the setting of pre-ESRD nephrology care influences initiation of dialysis and mortality is not known.

Objective  To compare initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-ESRD nephrology care in fee-for-service Medicare vs the Department of Veterans Affairs (VA).

Design, Setting, and Participants  Retrospective cohort study of patients from the US Medicare and VA health care systems evaluated 11 215 veterans aged 67 years or older with incident kidney failure between January 1, 2008, and December 31, 2011. Data analysis was performed March 15, 2016, through September 20, 2017.

Exposures  Pre-ESRD nephrology care in Medicare vs VA health care systems.

Main Outcome and Measures  Dialysis treatment and death within 2 years.

Results  Of the 11 215 patients included in the study, 11 085 (98.8%) were men; mean (SD) age was 79.1 (6.9) years. Within 2 years of incident kidney failure, 7071 (63.0%) of the patients started dialysis and 5280 (47.1%) died. Patients who received pre-ESRD nephrology care in Medicare were more likely to undergo dialysis compared with patients who received pre-ESRD nephrology care in VA (82% vs 53%; adjusted risk difference, 28 percentage points; 95% CI, 26-30 percentage points). Differences in dialysis initiation between Medicare and VA were more pronounced among patients aged 80 years or older and patients with dementia or metastatic cancer, and less pronounced among patients with paralysis (P < .05 for interaction). Two-year mortality was higher for patients who received pre-ESRD care in Medicare compared with VA (53% vs 44%; adjusted risk difference, 5 percentage points; 95% CI, 3-7 percentage points). The findings were similar in a propensity-matched analysis.

Conclusions and Relevance  Veterans who receive pre-ESRD nephrology care in Medicare receive dialysis more often yet are also more likely to die within 2 years compared with those in VA. The VA’s integrated health care system and financing appear to favor lower-intensity treatment for kidney failure in older patients without a concomitant increase in mortality.

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