Comparison of outcomes for veterans receiving dialysis care from VA and non-VA providers

Abstract

BackgroundDemand for dialysis treatment exceeds its supply within the Veterans Health Administration (VA), requiring VA to outsource dialysis care by purchasing private sector dialysis for veterans on a fee-for-service basis. It is unclear whether outcomes are similar for veterans receiving dialysis from VA versus non-VA providers. We assessed the extent of chronic dialysis treatment utilization and differences in all-cause hospitalizations and mortality between veterans receiving dialysis from VA versus VA-outsourced providers.MethodsWe constructed a retrospective cohort of veterans in 2 VA regions who received chronic dialysis treatment financed by VA between January 2007 and December 2008. From VA administrative data, we identified veterans who received outpatient dialysis in (1) VA, (2) VA-outsourced settings, or (3) both (“dual”) settings. In adjusted analyses, we used two-part and logistic regression to examine associations between dialysis setting and all-cause hospitalization and mortality one-year from veterans’ baseline dialysis date.ResultsOf 1,388 veterans, 27% received dialysis exclusively in VA, 47% in VA-outsourced settings, and 25% in dual settings. Overall, half (48%) were hospitalized and 12% died. In adjusted analysis, veterans in VA-outsourced settings incurred fewer hospitalizations and shorter hospital stays than users of VA due to favorable selection. Dual-system dialysis patients had lower one-year mortality than veterans receiving VA dialysis.ConclusionsVA expenditures for “buying” outsourced dialysis are high and increasing relative to “making” dialysis treatment within its own system. Outcomes comparisons inform future make-or-buy decisions and suggest the need for VA to consider veterans’ access to care, long-term VA savings, and optimal patient outcomes in its placement decisions for dialysis services.

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y₁₂ Inhibitors among Veterans

“…On the other hand, we found the period prevalence of dialysis-dependent CKD to be much higher than the general population (2.4 vs. <1%). Our findings are similar to recent studies that reported higher incidence of dialysis-dependent CKD among Veterans compared to the non-Veteran population [10,11]. A majority of the Veteran population that develops dialysis-dependent CKD chooses VA as the primary payer over Medicare, given the large differences in out-of-pocket medication co-payments or reimbursements, which is much less in the VA.…”

“…Hence, it is not surprising that we found 56.7% of thrombotic CV events to be associated with CKD diagnosis. This may be an underestimation of the true burden of thrombotic CV events among Veterans with CKD as only about half of the Veterans with CKD enrolled in VA care use either the VA system exclusively or dually with non-VA care [10]. Our data underline the importance of future CV research among Veterans with CKD -a subgroup that has been relatively understudied than the nonVeteran population.…”

Comparing VA and Non-VA Quality of Care: A Systematic Review

“…31 Veterans undergoing dialysis treatment in VA and non-VA settings experienced similar mortality. 32 Adjusted mortality was lower among male VA patients compared with male Medicare Advantage beneficiaries over 65 years old; [33][34][35][36] results were similar for females. 34 Mortality within 1 year of admission after hip fracture was 21 % lower among veterans admitted to non-VA hospitals compared with VA patients.…”

“…37 Four studies examined equity, with one study showing better performance on several chronic disease and preventive measures, 51 one study showing worse performance in VA facilities for emergency room visits among cancer patients in the last month of life, 76 and two studies showing similar equity in 30-day post-admission mortality 78 and graft failure. 27 Nine articles compared efficiency using utilization, with six studies showing worse performance in VA facilities on outcomes such as average length of stay and service utilization for patients on dialysis, 32,61,[79][80][81][82] two showing better performance for visits/ admissions 83 and generic drug utilization, 84 and one with mixed results for utilization-related inpatient quality indicators. Five studies examined patient-centeredness; three studies demonstrated better patient and family satisfaction in VA facilities 77,85,86 and two demonstrated similar performance in perceptions of racial discrimination and satisfaction in transitional programs for homeless veterans.…”

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

“…In terms of other types of utilization, Wang et al (2013b) found that Veteran patients who exclusively received dialysis at VA-outsourced settings were less likely than Veteran patients exclusively receiving VA dialysis to be hospitalized within a year, and had shorter length of stay than VA users. Hynes et al (2011) compared VA hemodialysis patients with private-sector hemodialysis patients and found that VA patients had more non-dialysis outpatient visits, emergency room visits, 30-day supplies of prescriptions, inpatient admissions for acute medical or surgical care, and hospital days, but no difference in non-acute admissions and days of care.…”