Predialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services.
OBJECTIVE
To examine the effect of exclusive and dual use of Department of Veterans Affairs (VA) and Medicare healthcare systems on outpatient predialysis nephrology care.


METHODS
Retrospective cohort study.


METHODS
Receipt, timeliness, and intensity of predialysis nephrology care were evaluated among 8033 veterans who initiated dialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage in the 12 months preceding dialysis initiation. Propensity scores were incorporated into analyses to minimize potential selection bias from nonrandom veteran allocation to healthcare systems.


RESULTS
Among the cohort, 17.4% were users of VA services only (VA-only users), 38.5% were users of Medicare-covered services only (Medicare-only users), and 44.1% were users of both VA and Medicare-covered services (dual users). Sixty-six percent of VA-only and dual users and 58.1% of Medicare-only users received predialysis nephrology care. Compared with Medicare-only users, dual users were more likely (risk ratio [RR], 1.12; 95% confidence interval [CI], 1.07-1.17) and VA-only users were as likely (RR, 0.98; 95% CI, 0.88-1.08) to have received predialysis nephrology care. Compared with Medicare-only use, VA-only use (RR, 0.63; 95% CI, 0.50-0.81) and dual use (RR, 0.78; 95% CI, 0.70-0.88) were associated with a lower likelihood of late nephrology care (<3 months before dialysis initiation).


CONCLUSIONS
More than one-third of older veterans initiating dialysis do not receive nephrology care beforehand. Dual use of VA and Medicare-covered services was associated with greater receipt and favorable timeliness of predialysis nephrology care, while use of only Medicare-covered services was associated with late predialysis nephrology care. Further studies to identify reasons for system-level variations in access to predialysis nephrology care may assist in identifying opportunities for improvement.
Center for Management of Complex Chronic Care, Edward Hines, Jr VA Medical Center, 5000 S 5th Ave (151H), Hines, IL 60141, USA. fischerm@uic.edu
Michael J
MJ
Fischer
Kevin T
KT
Stroupe
James S
JS
Kaufman
Ann M
AM
O'Hare
Margaret M
MM
Browning
Zhiping
Z
Huo
Denise M
DM
Hynes
D000368:Aged; D000553:Ambulatory Care; D015331:Cohort Studies; D005260:Female; D006801:Humans; D019458:Insurance Coverage; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D006278:Medicare; D009398:Nephrology; D012189:Retrospective Studies; D014481:United States; D014728:Veterans