COMMENTARY

Dialysis Use and Mortality in Medicare Versus Veterans Affairs

Nisha Bansal, MD, MAS

Disclosures

June 22, 2018

The benefits of dialysis initiation remain controversial in older adults, who often have a high burden of comorbidity. Studies have suggested that in these patients, dialysis may not provide survival benefit or improved quality of life. Furthermore, it is plausible that in this subset of patients, dialysis may actually lead to greater morbidity—eg, complications related to dialysis (such as infections) and greater rates of hospitalization.

To this end, clinical guidelines advocate for shared decision-making about dialysis initiation, which should take into account patient preferences, expected quality of life, and overall prognosis with dialysis. With these guidelines, it is unclear whether rates of dialysis initiation differ by practice setting (which is diverse within the United States) and whether differences in dialysis rates across practice settings lead to differential patient outcomes.

The Study

To answer these questions, a recent publication by Kurella Tamura and colleagues in JAMA Internal Medicine compared initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-end stage renal disease (ESRD) nephrology care in fee-for-service Medicare versus the Department of Veterans Affairs (VA).[1]

To conduct the study, the authors used laboratory and administrative data from the VA, Medicare claims, and the US Renal Data System. They included patients > 67 years of age, those with pre-ESRD nephrology at either the VA or through Medicare, and those who developed incident kidney failure between 2008 and 2011. Incident kidney failure was defined as progression to a sustained estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2 during the follow-up period (determined by at least two eGFR measurements) or initiation of maintenance dialysis. The primary exposure was pre-ESRD nephrology care (Medicare versus VA) over 2 years before incident kidney failure. The primary outcomes for the study were treatment with maintenance dialysis and mortality within 2 years of incident kidney failure.

The study population included 3974 Medicare patients and 7241 VA patients. Medicare patients were more likely than VA patients to be older, male, white, and married. Within 2 years, 82% of Medicare patients and 53% of VA patients started dialysis. The relative risk of starting dialysis for Medicare patients (versus VA patients) was 1.53 (95% confidence interval, 1.48-1.57). Differences between Medicare and VA patients in the frequency of dialysis treatments were larger among patients aged 80 years or older and among patients with dementia or metastatic cancer. There was no evidence of differences by race.

Within 2 years of incident kidney failure, 47% of the patients died overall. Among patients who started dialysis, the mortality rate was 54% in the Medicare group versus 43% in the VA group. Among all patients with kidney failure, the mortality rate was 53% in the Medicare group versus 44% in the VA group.

From this study, the authors concluded that in a national, contemporary cohort of older patients with incident kidney failure, patients who received pre-ESRD nephrology care in Medicare had a markedly higher frequency of dialysis initiation than those who received care in the VA. Despite more frequent initiation of dialysis, patients who received care in Medicare were not more likely than those who received care in the VA to have better survival.

Viewpoint

The study highlights how differences in the structure and delivery of care results in heterogeneity in the delivery of a high-cost treatment, such as dialysis, in a population with uncertain benefits. There are several plausible reasons why care in the VA may differ from that in other settings. The VA offers integrated subspecialty care, which may facilitate the coordinated care plan for medically complex patients, such as those with advanced chronic kidney disease. Also, the physicians salaried by the VA do not receive direct financial incentives to initiate dialysis. Finally, the VA has prioritized support for palliative care services, which is particularly important in the older population with advanced chronic kidney disease.

A strength of this study is its use of a large, national population. However, the authors were unable to determine patient preferences for dialysis, as well as other unmeasured factors that may have influenced decisions about dialysis initiation and subsequent risk for mortality.

This study raises many questions about healthcare delivery systems and support infrastructure for shared decision-making about dialysis initiation among patients with chronic kidney disease. Hopefully, further research in this area will inform best practice in order to improve the care and survival of the large and vulnerable population of patients with advanced chronic kidney disease.

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