Center for Management of Complex Chronic Care, Edward Hines, Jr VA Medical Center, 5000 S 5th Ave (151H), Hines, IL 60141, USA.
Am J Manag Care. 2010 Feb 1;16(2):e57-66.
To examine the effect of exclusive and dual use of Department of Veterans Affairs (VA) and Medicare healthcare systems on outpatient predialysis nephrology care.
Retrospective cohort study.
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.
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).
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.
研究退伍军人事务部（VA）和医疗保险系统的单独使用和双重使用对透析前肾脏病学治疗的影响。
回顾性队列研究。
对 2000 年和 2001 年开始透析且在透析前 12 个月内有资格同时享受 VA 和医疗保险覆盖的 8033 名退伍军人，评估他们接受透析前肾脏病学治疗的情况，包括接受程度、及时性和强度。采用倾向评分分析，以尽量减少退伍军人对医疗系统非随机分配造成的潜在选择偏差。
队列中有 17.4%的退伍军人仅使用 VA 服务（VA 仅使用者），38.5%的退伍军人仅使用医疗保险覆盖的服务（医疗保险仅使用者），44.1%的退伍军人同时使用 VA 和医疗保险覆盖的服务（双重使用者）。66%的 VA 仅使用者和双重使用者以及 58.1%的医疗保险仅使用者接受了透析前肾脏病学治疗。与医疗保险仅使用者相比，双重使用者更有可能（风险比[RR]，1.12；95%置信区间[CI]，1.07-1.17），VA 仅使用者也有可能（RR，0.98；95%CI，0.88-1.08）接受透析前肾脏病学治疗。与医疗保险仅使用者相比，VA 仅使用者（RR，0.63；95%CI，0.50-0.81）和双重使用者（RR，0.78；95%CI，0.70-0.88）接受晚期肾脏病学治疗（<透析前 3 个月）的可能性较低。
超过三分之一的开始透析的老年退伍军人在此之前未接受肾脏病学治疗。VA 和医疗保险覆盖服务的双重使用与接受透析前肾脏病学治疗的比例更高和及时性更好相关，而仅使用医疗保险覆盖服务与透析前晚期肾脏病学治疗相关。进一步研究确定系统层面获得透析前肾脏病学治疗的差异的原因，可能有助于确定改进的机会。
