Health Services Research and Development, Durham VA Medical Center, Durham, NC, 27705, USA.
BMC Health Serv Res. 2013 Jan 18;13:26. doi: 10.1186/1472-6963-13-26.
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.
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.
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.
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.
退伍军人健康管理局（VA）的透析治疗需求超过供应，这需要 VA 通过按服务收费的方式从私营部门购买透析来为退伍军人提供透析治疗。目前尚不清楚退伍军人从 VA 还是非 VA 供应商处获得透析治疗的结果是否相似。我们评估了退伍军人接受慢性透析治疗的程度，并比较了退伍军人从 VA 还是 VA 外包供应商处接受透析治疗的全因住院和死亡率差异。
我们构建了一个回顾性队列，纳入了 2007 年 1 月至 2008 年 12 月期间在 2 个 VA 地区接受 VA 资助的慢性透析治疗的退伍军人。从 VA 行政数据中，我们确定了在以下三种情况下接受门诊透析治疗的退伍军人：（1）VA 内，（2）VA 外包环境中，或（3）同时在两种环境中（双重）。在调整分析中，我们使用两部分和逻辑回归来检查退伍军人基线透析日期后一年的透析设置与全因住院和死亡率之间的关联。
在 1388 名退伍军人中，27%的退伍军人仅在 VA 接受透析治疗，47%的退伍军人在 VA 外包环境中接受透析治疗，25%的退伍军人同时在 VA 和 VA 外包环境中接受透析治疗。总体而言，有一半（48%）退伍军人住院，12%的退伍军人死亡。在调整分析中，由于选择偏倚，与 VA 使用者相比，VA 外包环境中的退伍军人住院次数较少，住院时间较短。双重系统透析患者的一年死亡率低于接受 VA 透析的退伍军人。
VA 为“购买”外包透析而支出的费用相对于在其自身系统中“制造”透析治疗的费用而言是高的，且呈上升趋势。结果比较为未来的制造或购买决策提供了信息，并表明 VA 在其透析服务安置决策中需要考虑退伍军人的护理机会、长期 VA 节省和最佳患者结果。
