title: Comparison of outcomes for veterans receiving dialysis care from VA and non-VA providers.
abstract: BACKGROUND
  Demand for dialysis treatment exceeds its supply within the Veterans Health Administration (VA), requiring VA to outsource dialysis care by purchasing private sector dialysis for veterans on a fee-for-service basis. It is unclear whether outcomes are similar for veterans receiving dialysis from VA versus non-VA providers. We assessed the extent of chronic dialysis treatment utilization and differences in all-cause hospitalizations and mortality between veterans receiving dialysis from VA versus VA-outsourced providers.
  
  
  METHODS
  We constructed a retrospective cohort of veterans in 2 VA regions who received chronic dialysis treatment financed by VA between January 2007 and December 2008. From VA administrative data, we identified veterans who received outpatient dialysis in (1) VA, (2) VA-outsourced settings, or (3) both ("dual") settings. In adjusted analyses, we used two-part and logistic regression to examine associations between dialysis setting and all-cause hospitalization and mortality one-year from veterans' baseline dialysis date.
  
  
  RESULTS
  Of 1,388 veterans, 27% received dialysis exclusively in VA, 47% in VA-outsourced settings, and 25% in dual settings. Overall, half (48%) were hospitalized and 12% died. In adjusted analysis, veterans in VA-outsourced settings incurred fewer hospitalizations and shorter hospital stays than users of VA due to favorable selection. Dual-system dialysis patients had lower one-year mortality than veterans receiving VA dialysis.
  
  
  CONCLUSIONS
  VA expenditures for "buying" outsourced dialysis are high and increasing relative to "making" dialysis treatment within its own system. Outcomes comparisons inform future make-or-buy decisions and suggest the need for VA to consider veterans' access to care, long-term VA savings, and optimal patient outcomes in its placement decisions for dialysis services.
authors: Health Services Research and Development, Durham VA Medical Center, Durham, NC, 27705, USA. virginia.wang@duke.edu
authors: Virginia
authors: V
authors: Wang
authors: Matthew L
authors: ML
authors: Maciejewski
authors: Uptal D
authors: UD
authors: Patel
authors: Karen M
authors: KM
authors: Stechuchak
authors: Denise M
authors: DM
authors: Hynes
authors: Morris
authors: M
authors: Weinberger
mesh_terms: D000368:Aged; D005260:Female; D006268:Health Facilities / Q000145:classification* / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D006435:Renal Dialysis / Q000401:mortality; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans