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Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs.
Clin J Am Soc Nephrol. 2015 Aug 07; 10(8):1418-27.CJ

Abstract

BACKGROUND AND OBJECTIVES

The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m(2).

RESULTS

The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m(2) increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001).

CONCLUSIONS

Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk.

Authors+Show Affiliations

Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Nephrology, Department of Medicine, and Kidney Research Institute, Seattle, Washington mkyu@uw.edu.Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Nephrology, Department of Medicine, and Kidney Research Institute, Seattle, Washington.Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington;Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington;Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington;Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; and.Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington School of Public Health, Seattle, Washington; and.

Pub Type(s)

Comparative Study
Journal Article
Research Support, U.S. Gov't, Non-P.H.S.

Language

eng

PubMed ID

26206891

Citation

Yu, Margaret K., et al. "Trends in Timing of Dialysis Initiation Within Versus Outside the Department of Veterans Affairs." Clinical Journal of the American Society of Nephrology : CJASN, vol. 10, no. 8, 2015, pp. 1418-27.
Yu MK, O'Hare AM, Batten A, et al. Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs. Clin J Am Soc Nephrol. 2015;10(8):1418-27.
Yu, M. K., O'Hare, A. M., Batten, A., Sulc, C. A., Neely, E. L., Liu, C. F., & Hebert, P. L. (2015). Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs. Clinical Journal of the American Society of Nephrology : CJASN, 10(8), 1418-27. https://doi.org/10.2215/CJN.12731214
Yu MK, et al. Trends in Timing of Dialysis Initiation Within Versus Outside the Department of Veterans Affairs. Clin J Am Soc Nephrol. 2015 Aug 7;10(8):1418-27. PubMed PMID: 26206891.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Trends in Timing of Dialysis Initiation within Versus Outside the Department of Veterans Affairs. AU - Yu,Margaret K, AU - O'Hare,Ann M, AU - Batten,Adam, AU - Sulc,Christine A, AU - Neely,Emily L, AU - Liu,Chuan-Fen, AU - Hebert,Paul L, Y1 - 2015/07/23/ PY - 2014/12/23/received PY - 2015/04/30/accepted PY - 2015/7/25/entrez PY - 2015/7/25/pubmed PY - 2016/5/11/medline KW - Department of Veterans Affairs KW - dialysis initiation KW - health system SP - 1418 EP - 27 JF - Clinical journal of the American Society of Nephrology : CJASN JO - Clin J Am Soc Nephrol VL - 10 IS - 8 N2 - BACKGROUND AND OBJECTIVES: The secular trend toward dialysis initiation at progressively higher levels of eGFR is not well understood. This study compared temporal trends in eGFR at dialysis initiation within versus outside the Department of Veterans Affairs (VA)-the largest non-fee-for-service health system in the United States. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The study used linked data from the US Renal Data System, VA, and Medicare to compare temporal trends in eGFR at dialysis initiation between 2000 and 2009 (n=971,543). Veterans who initiated dialysis within the VA were compared with three groups who initiated dialysis outside the VA: (1) veterans whose dialysis was paid for by the VA, (2) veterans whose dialysis was not paid for by the VA, and (3) nonveterans. Logistic regression was used to estimate average predicted probabilities of dialysis initiation at an eGFR≥10 ml/min per 1.73 m(2). RESULTS: The adjusted probability of starting dialysis at an eGFR≥10 ml/min per 1.73 m(2) increased over time for all groups but was lower for veterans who started dialysis within the VA (0.31; 95% confidence interval [95% CI], 0.30 to 0.32) than for those starting outside the VA, including veterans whose dialysis was (0.36; 95% CI, 0.35 to 0.38) and was not (0.40; 95% CI, 0.40 to 0.40) paid for by the VA and nonveterans (0.39; 95% CI, 0.39 to 0.39). Differences in eGFR at initiation within versus outside the VA were most pronounced among older patients (P for interaction <0.001) and those with a higher risk of 1-year mortality (P for interaction <0.001). CONCLUSIONS: Temporal trends in eGFR at dialysis initiation within the VA mirrored those in the wider United States dialysis population, but eGFR at initiation was consistently lowest among those who initiated within the VA. Differences in eGFR at initiation within versus outside the VA were especially pronounced in older patients and those with higher 1-year mortality risk. SN - 1555-905X UR - https://www.unboundmedicine.com/medline/citation/26206891/Trends_in_Timing_of_Dialysis_Initiation_within_Versus_Outside_the_Department_of_Veterans_Affairs_ L2 - https://cjasn.asnjournals.org/cgi/pmidlookup?view=long&amp;pmid=26206891 DB - PRIME DP - Unbound Medicine ER -