Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings

Abstract

Background: Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements.

Methods: We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at (1) VA-based units, (2) community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), (3) community-based clinics under Medicare, or (4) more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics.

Results: Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings.

Conclusions: Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.

Keywords: Medicare; Veterans Affairs; community care; dialysis; end-stage renal disease; mortality.

Figure 1.

The majority of veterans receive dialysis in non-VA settings and dual VA and non-VA settings in the 2 years after dialysis initiation.

Figure 2.

Unadjusted survival is lower in non-VA, compared to VA and dual dialysis settings. Time (in days) from dialysis initiation to renal transplantation, death, or end of follow-up period of observation. + denotes censored event (renal transplant or end of follow-up). Because of sample exclusion criteria, there are no observed deaths in the first 90 days after dialysis initiation.

Figure 3.

After adjustment in a Cox proportional hazards model, veterans' 2-year survival is lowest and nearly equivalent across both non-VA dialysis settings and higher in VA and dual settings. Direct adjusted survival functions, by dialysis setting (with time assessed quarterly), from dialysis initiation to censoring at renal transplantation or end of follow-up period of observation. Because of sample exclusion criteria, there are no observed deaths in the first 90 days after dialysis initiation. Estimated 2-year mortality rates were generated from the Cox regression model, adjusting for patient baseline demographic, clinical, financial, and geographic access characteristics (full set of model estimates are available in Supplemental Table 1).