Dialysis Provider and Outcomes among United States Veterans Who Transition to Dialysis

Abstract

Background and objectives: Veterans with ESKD initiate dialysis under the Veterans Health Administration (VHA), an integrated health system, or are outsourced to non-VHA providers. It is unknown whether outcomes differ according to their dialysis provider at initiation. We sought to evaluate the association between dialysis provider and mortality and hospitalization among United States veterans initiating dialysis.

Design, setting, participants, & measurements: Among 68,727 United States veterans who initiated dialysis in 2007-2014, we examined the association of dialysis provider (VHA versus non-VHA) at initiation with mortality and hospitalization rates in the first 12 months post-initiation. Associations were examined across adjusted models, accounting for demographics and comorbidities.

Results: Patients were 72±11 years, 5% were women, 24% were black, and 10% (n=7584) initiated at VHA dialysis centers. VHA dialysis center patients were younger, more likely to be black, had fewer cardiovascular comorbidities, and lower eGFR at dialysis initiation. VHA provider patients were more likely to be hospitalized in the first 12 months (adjusted incidence rate ratio, 1.10; 95% confidence interval, 1.07 to 1.14), but had lower all-cause mortality risk (adjusted hazard ratio, 0.87; 95% confidence interval, 0.83 to 0.93) in fully adjusted models.

Conclusions: Veteran patients initiating dialysis with a VHA dialysis provider appear to have a lower mortality risk but higher hospitalization rates than veterans initiating dialysis at non-VHA dialysis units.

Keywords: Comorbidity; Dialysis Initiation; Dialysis Provider; Female; Humans; Incidence; Kidney Failure, Chronic; Odds Ratio; Risk; Veterans; glomerular filtration rate; hospitalization; mortality; renal dialysis.

Graphical abstract

Figure 1.

Veterans with a VHA (versus non-VHA) baseline dialysis provider had lower mortality in 68,727 veterans who initiated dialysis between October of 2007 and March of 2014. (A) Annualized mortality rates showing lower mortality rates for VHA (B) Kaplan Meier showing a slower decrease in survival over time for VHA.

Figure 2.

Association of VHA (versus non-VHA) baseline dialysis provider over 12 months follow-up in a priori selected subgroups. Patients with VHA (versus non-VHA) baseline dialysis provider experienced lower all-cause mortality risk (A) yet higher hospitalization rates (B) over 12 months of follow-up across most examined a priori selected subgroups. AV, arteriovenous; CVC, central venous catheter; mi, miles; PTSD, post-traumatic stress disorder; SES, socioeconomic status; zip dist, zip code distance to provider.