Medicare pre-ESRD care results in more dialysis initiation but also increased two-year mortality

1. Veterans receiving pre-end stage renal disease (ESRD) nephrology care in under the Medicare system were more likely to undergo dialysis and had a higher two-year mortality rate than veterans that received pre-ESRD care through the Department of Veteran’s Affairs (VA).

2. Differences in dialysis initiation between Medicare and VA were more pronounced in patients that were older, had metastatic cancer or dementia.

Evidence Rating Level: 2 (Good)

Study Rundown: Maintenance dialysis in older patients with end-stage renal disease (ESRD) has uncertain benefit and thus delaying dialysis initiation may provide better patient outcomes. However, it is unclear whether the setting of pre-ESRD nephrology care influences the rate of initiation of dialysis or mortality. This retrospective cohort study aimed to compare the initiation of dialysis and mortality among older veterans with incident kidney failure who received pre-ESRD nephrology care in fee-for-service Medicare vs. the Department of Veteran’s Affairs (VA).

Veterans who receive pre-ESRD nephrology care in Medicare were more likely to receive dialysis and were also more likely to die within 2 years as compared to those within the VA system. The differences in dialysis initiation between Medicare and VA were more pronounced in patients aged 80 and older, patients with metastatic cancer and those with dementia. Strengths of this study include its large size and thus ability to evaluate two health care systems in regards to mortality. Limitations include uncertainty in the number of incident cases of kidney failure without dialysis in Medicare, thus may impact the estimates of the differences in initiation of dialysis treatment.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis

In-Depth [retrospective cohort]: This retrospective cohort study was conducted between January 2008 and December 2011 using US Medicare and VA health care system information for 11 215 veterans aged 67 and older with new kidney failure. The exposure of interest was pre-ESRD nephrology care in Medicare vs. VA health care systems and veterans were followed for the outcome of maintenance dialysis initiation and death within 2 years of incident kidney failure. Outcomes were identified using International Classification of Disease Version 9-CM or Current Procedural Terminology codes. Patients were followed until December 31, 2013 thus allowing for at least two years of follow-up.

Of the 11 215 patients included in the study the mean (SD) age was 79.1 (6.9) years. Patients who received pre-ESRD nephrology care in Medicare were more likely to be started on maintenance dialysis as compared to patients in the VA system (82% vs. 53%; adjusted risk difference 28 percentage points; 95% CI 26-30 percentage points). Two-year mortality was also higher in patients who received pre-ESRD care through Medicare as compared to VA (53% vs. 44%; adjusted risk difference 5 percentage points; 95% CI 3-7 percentage points).

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