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Dialysis, common among veterans in Medicare, does not improve mortality rates

Older veterans on Medicare receiving nephrology care initiated dialysis more often but were also more likely to die than those receiving care in the Veterans Affairs health care system, according to findings published in JAMA Internal Medicine.

“The benefits of maintenance dialysis for older adults with end-stage renal disease (ESRD) are uncertain,” Manjula Kurella Tamura, MD, MPH, professor of nephrology at the Geriatric Research and Education Clinical Center at the Veterans Affairs Palo Alto Health Care System, and colleagues wrote. “Whether the setting of pre-ESRD nephrology care influences initiation of dialysis and mortality is not known.”

Kurella Tamura and colleagues performed a retrospective cohort study to compare rates of dialysis initiation and mortality among veterans aged 67 years or older (n = 11,215; mean age, 79.1 years; 98.8% men) with incident kidney failure between Jan. 1, 2008, and Dec. 31, 2011, treated for pre-ESRD in fee-for-service Medicare vs. VA.

The researchers found that 63% of patients initiated dialysis and 47.1% of patients died within 2 years of incident kidney failure. Dialysis was more common in patients who received pre-ERSD nephrology care in Medicare than in VA (82% vs. 53%; adjusted risk difference = 28 percentage points; 95% CI, 26-30). Patients aged 80 years or older and those with dementia or metastatic cancer showed more marked differences in the initiation of dialysis, whereas those with paralysis showed less marked differences.

Patients who received pre-ESRD care in Medicare had higher mortality rates after 2 years than those in VA (53% vs 44%; adjusted risk difference = 5 percentage points; 95% CI, 3-7). Propensity-matched analyses indicated similar results.

“Dialysis appears to be the default treatment option for the majority of older veterans who receive pre-ESRD care in Medicare, but this pattern of care was not associated with better overall survival,” Kurella Tamura and colleagues concluded. “Additional studies may help to determine the specific processes of care associated with these findings and whether they can be replicated among the rapidly growing number of integrated delivery systems outside of the VA.”

In an accompanying editorial, Zijn Chen, MD, and Chi-yuan Hsu, MD, MSc, both from the University of California, San Francisco, wrote that the findings by Kurella Tamura and colleagues build upon the knowledge base regarding temporal trends in dialysis initiation.

“Given the many unknown factors, the decision on when it is best to initiate dialysis should evoke humility,” they wrote. “The goal should be to encourage thoughtful, joint decision-making by nephrologists and their patients. The system should reinforce the careful weighing of pros and cons by supporting health care professionals in caring for patients with very low eGFR, and financial incentives should be realigned so that we do not inadvertently pressure patients to receive dialysis earlier than would be best for them.” – by Alaina Tedesco

Disclosures: Kurella Tamura and colleagues report no relevant financial disclosures. Chen reports receiving support from International Society of Nephrology and National Natural Science Foundation of China. Hsu reports being the medical director of the San Francisco Wellbound dialysis unit and receiving research funding from Satellite Healthcare Inc. and support from the NIH.