BACKGROUND/RATIONALE:
In 1999, more than 4,400 patients received hemodialysis in Veterans Affairs (VA) facilities at an estimated cost over $60 million. However, dialysis is a limited resource in the VA, and some VAs may require additional fee-basis care to meet patients’ needs. The total costs of care and impacts on patients’ outcomes of receiving care in VA or non-VA dialysis facilities are not known. If in fact large differences in care costs or outcomes do exist, hemodialysis care options for the VA may need to be changed.
OBJECTIVE(S):
This prospective observational study examined the complex incentives for care for end stage renal disease (ESRD) patients in 8 VA facilities. The primary objective was to determine whether costs of providing ESRD care and health-related quality of life (HRQOL) differed for veterans who received their hemodialysis at VA versus non-VA facilities.
METHODS:
Veterans were recruited from August 2001 through December 2003. Patients were followed for six months, or if they were new dialysis patients, 12 months. Data collected included demographics, clinical characteristics and health-related quality of life (HRQOL). Total health care costs for all patients were computed using micro-costing analyses, Medicare’s Renal Cost Reports, and VA and Medicare administrative databases.
FINDINGS/RESULTS:
Three hundred sixty-four veterans consented to participate in the study and 344 were subsequently enrolled: 188 dialyzing in VA facilities, 132 dialyzing in private-sector facilities, and 24 dialyzing at private-sector facilities as VA fee-basis patients. There were significant differences in age, race, marriage status and distance from the VA between the 3 groups of patients, with patients dialyzing at the VA younger, more African-American, less likely to be married, and living closer to the VA. The 132 veterans dialyzing at non-VA facilities were more likely to have insurance supplemental to Medicare and VA, either in the form of Medicaid or private insurance. Patients dialyzing at the VA were significantly more ill according to several health status measures: lower hemoglobin and albumin, more complications with diabetes and more drug dependence. HRQOL was not significantly different between the 188 patients dialyzing at the VA and the 156 (fee-basis included) dialyzing at non-VA facilities; patients dialyzing at VA facilities were more likely to report higher levels of staff encouragement.
IMPACT:
Findings from this study have been continuously reported at meetings and one manuscript has been submitted. Three related manuscripts focusing on trends in ESRD care have also been completed, supported in part by this project. Five additional manuscripts are in progress. Findings from this study have provided the basis for two subsequent studies: one led by Dr. Stroupe to investigate the predialysis phase of care and further characterize the dual insurance aspects affecting health care choice (IIR-02-244), and a new proposal to evaluate a chronic disease management program to improve the processes that will better identify and improve primary care for chronic renal failure patients. This ESRD cost-effectiveness study is among the first to compare patients who receive dialysis care at VA vs. non-VA facilities,. Veterans dually eligible for VA and Medicare benefits are of particular interest to VA and Medicare policymakers. Evaluating the alternative methods for dialysis provision and ESRD care in general will allow VA to determine whether provision of ESRD care by VA facilities, non-VA facilities, or both is the most efficient method.
PUBLICATIONS:
Journal Articles
- Hynes DM, Stroupe KT, Greer JW, Reda DJ, Frankenfield DL, Kaufman JS, Henderson WG, Owen WF, Rocco MV, Wish JB, Kang J, Feussner JR. Potential cost savings of erythropoietin administration in end-stage renal disease. American Journal of Medicine. 2002; 112(3): 169-75.
