Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure

Abstract

IMPORTANCE Current guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities.OBJECTIVE To assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use. DESIGN, SETTING, AND PARTICIPANTSThis cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System.

Value Placed on Comfort vs Life Prolongation Among Patients Treated With Maintenance Dialysis

“…Existing evidence suggests that the intensive patterns of end-of-life care experienced by patients receiving dialysis may be incongruent with the values, goals, and preferences of individual patients. Prior studies indicate that end-of-life care for patients receiving dialysis are more strongly and consistently associated with system-level and health care professional–level factors than with individual patient characteristics . In 1 study, bereaved family members of patients who received dialysis were more likely than those of patients with other serious illnesses to report that their loved one received unwanted care .…”

“…Prior studies indicate that end-of-life care for patients receiving dialysis are more strongly and consistently associated with system-level and health care professional-level factors than with individual patient characteristics. 3,5,6 In 1 study, bereaved family members of patients who received dialysis were more likely than those of patients with other serious illnesses to report that their loved one received unwanted care. 4 Several other studies suggest that patients with advanced kidney disease are more likely to prefer care that is directed at preserving quality of life, relieving pain, and promoting independence rather than care that is focused on increasing longevity.…”

Assessing trends and variability in outpatient dual testing for chronic kidney disease with urine albumin and serum creatinine, 2009–2018: a retrospective cohort study in the Veterans Health Administration System

“…Similarly, a recent study demonstrated significant facility-level variation in dialysis use within the VHA system, with an adjusted median rate ratio of 1.40. High-use facilities were less likely to serve patients from zip codes with high median income and more likely to serve patients who did not receive nephrology care in the previous year, while low-use facilities served more elderly patients and those living in non-metropolitan areas 29. Factors that could have potentially influenced dual SCr and UAlb testing patterns in our cohort include local subspecialty presence and expertise, care coordination, case mix and laboratory logistics.…”

“…High-use facilities were less likely to serve patients from zip codes with high median income and more likely to serve patients who did not receive nephrology care in the previous year, while low-use facilities served more elderly patients and those living in non-metropolitan areas. 29 Factors that could have potentially influenced dual SCr and UAlb testing patterns in our cohort include local subspecialty presence and expertise, care coordination, case mix and laboratory logistics. Establishing clearer standards for dual testing among patients without diabetes might be expected to result in less variation.…”