Association of Hospice Payer With Concurrent Receipt of Hospice and Dialysis Among US Veterans With End-stage Kidney Disease: A Retrospective Analysis of a National Cohort.
Association of Hospice Payer With Concurrent Receipt of Hospice and Dialysis Among US Veterans With End-stage Kidney Disease: A Retrospective Analysis of a National Cohort.
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DOI：
10.1001/jamahealthforum.2022.3708
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发表时间：
2022-10-07
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影响因子：
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通讯作者：
Mor, Vincent
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作者：
Wachterman, Melissa W;Corneau, Emily E;O'Hare, Ann M;Keating, Nancy L;Mor, Vincent
终末期肾病（ESKD）退伍军人同时接受临终关怀和透析的频率是否因临终关怀支付者-医疗保险、退伍军人健康管理局（VA）住院临终关怀或VA资助的社区临终关怀而异？这项对18420名接受临终关怀的ESKD退伍军人进行的回顾性横断面研究发现，接受VA资助的临终关怀服务的患者比接受Medicare资助的临终关怀的患者更有可能接受并发透析护理。无论临终关怀支付者是谁，VA支付了大多数并发透析治疗的费用，临终关怀住院时间的中位数为43天，而没有透析的情况下为4天。这项回顾性横断面研究的结果表明，医疗保险的更严格的临终关怀政策似乎限制了ESKD退伍军人同时接受透析和临终关怀，并可能与临终关怀住院时间的大幅减少有关。对于许多终末期肾病（ESKD）患者，医疗保险临终关怀福利排除了同时接受临终关怀和透析服务，迫使患者在继续透析或参加临终关怀之间做出选择。退伍军人健康管理局（VA）的更自由的临终关怀资格标准是否与ESKD患者同时透析和临终关怀的改善有关尚不清楚。通过临终关怀支付者调查美国退伍军人同时接受临终关怀和透析护理的频率，并调查同时接受透析的支付者。这是一项回顾性横断面研究，纳入了美国肾脏数据系统登记研究中的所有70577例VA入组者，这些入组者开始维持透析并于2007年至2016年死亡。数据分析时间为2021年4月至2022年8月。临终关怀支付者，无论是医疗保险，VA住院临终关怀，或VA资助的社区临终关怀（“VA社区护理”）。主要临终关怀诊断-ESKD vs非ESKD。同时接受临终关怀和透析服务（“同时护理”）。有18420名（26%）符合条件的ESKD退伍军人接受了临终关怀服务（平均[SD]年龄，75.4 [10.0]岁; 17457名[94.8%]男性; 2997名[16.3%]黑人，15162名[82.3%]白色，261名（1.4%）其他种族）。大多数样本（n = 16 465; 89%）接受临终关怀服务的医疗保险和5231（28%）继续接受透析后，临终关怀开始。在退伍军人住院临终关怀或退伍军人社区护理临终关怀中接受并发护理的退伍军人比例高于在医疗保险临终关怀中接受并发护理的退伍军人比例（分别为57%和41% vs 24%;均P <0.001）。无论临终关怀支付者如何，临终关怀启动后的大多数（87%）透析治疗都由VA资助，包括患有ESKD以外临终关怀诊断的医疗保险受益人。接受同时透析的退伍军人的临终关怀住院时间中位数为43天，而没有接受透析的退伍军人为4天。在这项对ESKD美国退伍军人的回顾性横断面研究中，VA资助的临终关怀中的退伍军人在临终关怀开始后接受1次或多次透析治疗的比例明显高于参加Medicare资助的临终关怀的比例。不管临终关怀支付者是谁，退伍军人事务部资助了大多数并行透析治疗。临终关怀的用户谁收到并发透析护理有显着更长的临终关怀住院时间比那些谁没有。这些研究结果表明，医疗临终关怀政策可能会大大限制获得并发临终关怀和透析护理的退伍军人ESKD。这项回顾性横断面分析比较了美国退伍军人终末期肾病患者同时使用透析和临终关怀的情况，并检查了与住院时间的相关性。
Does the frequency of receiving concurrent hospice and dialysis among veterans with end-stage kidney disease (ESKD) vary by hospice payer—Medicare, Veterans Health Administration (VA) inpatient hospice, or VA-financed community-based hospice? This retrospective cross-sectional study of a national cohort of 18 420 veterans with ESKD who received hospice found that patients receiving VA-financed hospice services were more likely to receive concurrent dialysis care than those receiving Medicare-financed hospice. Irrespective of hospice payer, the VA paid for the majority of concurrent dialysis treatments with which median hospice length of stay was 43 days vs 4 days without dialysis. The findings of this retrospective cross-sectional study suggest that Medicare’s more restrictive hospice policy appears to limit access to concurrent dialysis and hospice care among veterans with ESKD and may be associated with a substantial reduction in length of hospice stay. For many patients with end-stage kidney disease (ESKD), the Medicare Hospice Benefit precludes concurrent receipt of hospice and dialysis services, forcing patients to choose between continuing dialysis or enrolling in hospice. Whether the more liberal hospice eligibility criteria of the Veterans Health Administration’s (VA) are associated with improved access to concurrent dialysis and hospice care for patients with ESKD is not known. To examine the frequency of concurrent hospice and dialysis care among US veterans by hospice payer and examine the payer for concurrent dialysis. This was a retrospective cross-sectional study of all 70 577 VA enrollees in the US Renal Data System registry who initiated maintenance dialysis and died in 2007 to 2016. Data were analyzed from April 2021 to August 2022. Hospice payer, either Medicare, VA inpatient hospice, or VA-financed community-based hospice (“VA community care”). Primary hospice diagnosis–ESKD vs non-ESKD. Concurrent receipt of hospice and dialysis services (“concurrent care”). There were 18 420 (26%) eligible veterans with ESKD who received hospice services (mean [SD] age, 75.4 [10.0] years; 17 457 [94.8%] men; 2997 [16.3%] Black, 15 162 [82.3%] White, and 261 (1.4%) individuals of other races). Most of the sample (n = 16 465; 89%) received hospice services under Medicare and 5231 (28%) continued to receive dialysis after hospice initiation. The adjusted proportion of veterans receiving concurrent care was higher for those enrolled in VA inpatient hospice or VA community care hospice than it was for those enrolled in Medicare hospice (57% and 41% vs 24%, respectively; both P < .001). Regardless of hospice payer, the majority (87%) of the dialysis treatments after hospice initiation were financed by the VA, including for Medicare beneficiaries who had a hospice diagnosis other than ESKD. Median hospice length of stay was 43 days for veterans who received concurrent dialysis vs 4 days for those who did not. In this retrospective cross-sectional study of US veterans with ESKD, a substantially higher proportion of veterans in VA-financed hospice received 1 or more dialysis treatments after hospice initiation than those enrolled in Medicare-financed hospice. Regardless of hospice payer, the VA financed most concurrent dialysis treatments. Hospice users who received concurrent dialysis care had substantially longer hospice lengths of stay than those who did not. These findings suggest that Medicare hospice policy may substantially restrict access to concurrent hospice and dialysis care among veterans with ESKD. This retrospective cross-sectional analysis compares the use of concurrent dialysis and hospice by payer among US veterans with end-stage kidney disease and examines the association with length of stay.