Not all kidney patients treated equal: Differences in care for patients beginning on dialysis

Kidney disease patients insured by some federally sponsored national health care organizations are more likely to undergo an important predialysis procedure than patients with other types of insurance, according to a study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN). The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis.

For patients whose kidneys no longer work, hemodialysis performs the work of the kidneys. Experts recommend creating an arteriovenous fistula (AVF), to connect a vein and artery and allow access to the vascular system. An AVF provides a long-lasting site through which blood can be removed and returned during the dialysis procedure, which patients must undergo 3-4 times per week.

While AVF use for hemodialysis access is safe, cost-effective, and associated with improved survival in kidney disease patients, only a minority of US patients start hemodialysis with an AVF (13.7% in 2008).

Frank Hurst, MD (Walter Reed Army Medical Center and F. Edward Hebert School of Medicine) and his colleagues evaluated the use of AVFs in federally sponsored national health care organizations such as the Departments of Veterans Affairs (DVA) and Department of Defense (DoD). Dr. Hurst and his team searched the United States Renal Data System (USRDS) database to identify patients who initiated hemodialysis between 2005 and 2006. They found that patients who received predialysis kidney care were 10 times as likely to begin dialysis with an AVF compared with patients who did not receive such care. Patients with DVA/DoD insurance were 40% more likely to initiate dialysis with an AVF compared with patients with other types of insurance. Specifically, 27.2% of patients with DVA/DoD insurance initiated hemodialysis with an AVF, compared with 18.5% of patients reporting employer-group insurance, 16.7% of patients with "Other" insurance, 15.6% of patients with Medicare, 13.0% of patients with Medicaid, and 8.2% of patients who reported no insurance. The analysis also revealed that patients who initiated hemodialysis at a DoD facility were twice as likely to use an AVF.

Experts are attempting to increase the use of AVFs through initiatives such as the Fistula First Breakthrough Coalition, whereby the Centers for Medicare & Medicaid Services, End Stage Renal Disease Networks, and the entire kidney community are working together to ensure that every suitable patient will receive the most optimal form of vascular access. Dr. Hurst's findings show that despite these efforts, AVF use is still highly dependent upon a patient's type of health insurance prior to the initiation of dialysis.

"Further study of these federal systems may identify practices that could improve processes of care across healthcare systems to increase the number of patients who initiate hemodialysis with an AVF," the authors wrote. They added that while AVF use is more frequent in DVA/DoD patients, the proportion of these patients who initiate hemodialysis with an AVF is still far too low.

Study co-authors include Kevin Abbott, MD (Walter Reed Army Medical Center and F. Edward Hebert School of Medicine); Dominic Raj, MD (George Washington University); Mahesh Krishnan, MD (Davita Clinical Research); Carlos Palant, MD (Washington DC VA Medical Center and George Washington University School of Medicine); Lawrence Agodoa, MD (National Institutes of Health); and Rahul Jindal, D, PhD (George Washington University, Walter Reed Army Medical Center, and Brookdale University Medical Center).

In an accompanying editorial, Steve Schwab, MD and Kennard Brown, PhD (University of Tennessee Health Science Center) expressed dismay that AVF placement before dialysis, which requires treatment by both a nephrologist and a vascular surgeon, is not covered by Medicare, which supports most coverage for dialysis. "We now have a public policy that treats a catastrophic illness such as renal failure but does not act to prevent or ameliorate that catastrophe earlier," they wrote. The authors advocate for amending policy guidelines so that patients can benefit from seeing specialists early in the course of their disease.

Disclosures: Dr. Krishnan is employed by Davita Clinical Research, an independent provider of dialysis services in the United States. All other authors reported no financial disclosures. Dr. Schwab and Dr. Brown, the authors of the editorial, reported no financial disclosures.

The views expressed in this article are those of the authors and do not reflect the official policy of the U.S. Government, the National Institutes of Health, the Department of Defense, the Department of Army, or Walter Reed Army Medical Center.

The article, "Arteriovenous Fistulas among Incident Hemodialysis Patients in Department of Defense and Veterans Affairs Facilities" (doi 10.1681/ASN.2010010025) and editorial, "Immature Public Policy for Vascular Access" (doi 10.1681/ASN.2010070771) will appear online at http://jasn.asnjournals.org/ on August 12, 2010.

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Founded in 1966, the American Society of Nephrology (ASN) is the world's largest professional society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists, ASN continues to promote expert patient care, to advance medical research, and to educate the renal community. ASN also informs policymakers about issues of importance to kidney doctors and their patients. ASN funds research, and through its world-renowned meetings and first-class publications, disseminates information and educational tools that empower physicians.