Differences in Pre-ESRD Care for VA versus Medicare Patients

Full access

Older veterans receiving pre-ESRD nephrology care in the Department of Veterans Affairs (VA) healthcare system have a lower rate of dialysis initiation—and lower mortality—than those receiving pre-ESRD care via Medicare, reports a study in JAMA Internal Medicine.

Using data from the VA, Medicare claims, and the US Renal Data System, the researchers identified 11,215 veterans aged 67 years or older who developed kidney failure from 2008 through 2011. Nearly 99% of patients were men; mean age was 79 years. Within 2 years after diagnosis of kidney failure, 63.0% of patients initiated dialysis and 47.1% died.

Dialysis initiation was

Older veterans receiving pre-ESRD nephrology care in the Department of Veterans Affairs (VA) healthcare system have a lower rate of dialysis initiation—and lower mortality—than those receiving pre-ESRD care via Medicare, reports a study in JAMA Internal Medicine.

Using data from the VA, Medicare claims, and the US Renal Data System, the researchers identified 11,215 veterans aged 67 years or older who developed kidney failure from 2008 through 2011. Nearly 99% of patients were men; mean age was 79 years. Within 2 years after diagnosis of kidney failure, 63.0% of patients initiated dialysis and 47.1% died.

Dialysis initiation was more likely for patients receiving pre-ESRD care via Medicare: 82% versus 53%, with an adjusted risk difference of 28 percentage points. The differences persisted on analysis of patients with at least two pre-ESRD visits and those with sustained estimated glomerular filtration rate of 15 mL/min/1.73 m2 or less. The difference in dialysis use was greater among patients aged 80 or older and those with dementia or metastatic cancer and less in those with paralysis.

Veterans receiving pre-ESRD care in Medicare had a higher 2-year mortality rate: 53% versus 44%, adjusted risk difference 5 percentage points. The outcome differences were similar on analysis of propensity score-matched groups of 2966 veterans who received pre-ESRD care in the VA system versus Medicare.

Differences in nephrology care before the development of ESRD may affect decisions about initiating dialysis. Most older veterans eligible for care in the VA healthcare system are also eligible for Medicare.

The new analysis shows differences in 2-year outcomes for older veterans treated in the VA system versus Medicare. “Default” treatment with dialysis under Medicare does not appear to lead to better overall survival. The investigators conclude, “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” [Tamura MK, et al. Dialysis initiation and mortality among older veterans with kidney failure treated in Medicare vs the Department of Veterans Affairs. JAMA Intern Med 2018; 178: 657–664].

Save