The decision to initiate maintenance dialysis for older veterans with end-stage renal disease affords one of the greatest opportunities to improve value in specialty care. Similar to other intensive procedures performed near the end of life, there are wide regional variations in the utilization of dialysis among older adults, suggesting that intensity of treatment for end-stage renal disease is determined by practice style or the supply of medical resources rather than the likelihood of benefit. The goal of this project is to determine the sources of variation underlying the decision to initiate dialysis and to identify specific patient, provider and facility characterstics associated with receipt of dialysis versus conservative (non-dialytic) care. This project will also compare the survival and health resource utilization patterns of dialysis versus conservative care management strategies. To accomplish this goal, we will assemble a national cohort of veterans approaching end-stage renal disease using VA claims data, laboratory records and detailed chart review. The findings from this project will inform the design of interventions and VA policies that promote appropriate use of dialysis.

Public Health Relevance

More than 27,000 veterans receive treatment for end-stage renal disease annually. The burden of end- stage renal disease among veterans is projected to double over the next decade, largely due to higher incidence and treatment rates of end-stage renal disease among veterans over the age of 75. Treatment of end-stage renal disease with maintenance dialysis is resource intensive and outcomes are often poor among older adults with serious comorbidity. This project will identify patient, provider and facility characteristics associated with dialysis initiation versus conservative care for older veterans with end-stage renal disease, and compare survival and healthcare utilization of the two treatment strategies. The findings will be used to help VA design and target policies and interventions promoting appropriate use of dialysis.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Blank (HSR7)
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Veterans Admin Palo Alto Health Care Sys
Palo Alto
United States
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Kurella Tamura, Manjula; Desai, Manisha; Kapphahn, Kristopher I et al. (2018) Dialysis versus Medical Management at Different Ages and Levels of Kidney Function in Veterans with Advanced CKD. J Am Soc Nephrol 29:2169-2177
Fung, Enrica; Chang, Tara I; Chertow, Glenn M et al. (2017) Receipt of Nephrology Care and Clinical Outcomes Among Veterans With Advanced CKD. Am J Kidney Dis 70:705-714
Morton, Rachael L; Kurella Tamura, Manjula; Coast, Joanna et al. (2016) Supportive Care: Economic Considerations in Advanced Kidney Disease. Clin J Am Soc Nephrol 11:1915-1920