Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure.
Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure.
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DOI：
10.1001/jamanetworkopen.2020.34084
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发表时间：
2021-01-04
影响因子：
13.8
通讯作者：
Kurella Tamura M
中科院分区：
文献类型：
--
作者：
Bradshaw C;Thomas IC;Montez-Rath ME;Lorenz KA;Asch SM;Leppert JT;Wang V;O'Hare AM;Kurella Tamura M
本队列研究检查了美国退伍军人事务部医疗保健系统中哪些患者和设施因素与透析方法和结局相关。在发生肾衰竭的老年人中，透析使用和死亡率的变化程度如何？这些变化是否与患者或机构因素有关？在这项对8695名发生肾衰竭的老年人进行的队列研究中，透析使用在退伍军人事务部设施中差异很大，死亡率差异很小。大多数的变化与患者的特征有关，没有发现透析使用率和死亡率之间的相关性。这项研究的结果表明，在退伍军人事务部机构中，老年人的透析使用实践存在显著差异。当前指南缺乏关于可能无法从透析中获益的患者治疗的共识;这种共识的缺乏可能与医疗保健机构之间透析使用和结局的显著差异有关。评估透析使用和死亡率的变化与患者而非机构特征相关的程度，并区分哪些特征确定了美国退伍军人事务部（VA）机构的透析使用率较高。这项队列研究分析了2011年1月1日至2014年12月31日期间进展为肾衰竭的3期或4期慢性肾病退伍军人的数据。这些患者在美国各地的VA机构接受护理。数据来源包括VA、Medicare和美国肾脏数据系统的实验室和管理记录。数据分析于2019年8月1日至2020年9月1日进行。主要暴露是VA机构，患者在发生肾衰竭事件（定义为首次发生持续估计肾小球滤过率低于15 mL/min/1.73 m2或开始维持透析）之前接受大部分护理。主要结局是透析使用和发生肾衰竭2年内的死亡率。使用中位率比来量化设施水平的变异，使用方差分配系数来量化无法解释的变异的来源。该队列包括8695名平均（SD）年龄为78.8（7.5）岁的老年退伍军人，主要是在108家VA机构接受治疗的男性（8573 [99%]）和白色（6102 [70%]）。各机构观察到的透析使用频率范围为25.0%-81.4%，中位（四分位距[IQR]）率为51.7%（48.4%-60.0%）。各机构观察到的死亡率范围为27.2%-60.0%，中位（IQR）率为45.2%（41.2%-48.6%）。透析使用的中位率比（根据多个患者和机构特征调整）为1.40，死亡率为1.08。两种结局中无法解释的变化主要来自患者特征，而不是机构特征。在设施水平上，透析使用与死亡率之间没有相关性（相关系数= 0.03）。该研究发现，老年人透析使用的差异很大，与设施水平的死亡率相关性很差，并且无法通过测量的患者和设施特征的差异来解释。这些发现表明，有机会提高透析使用实践与肾衰竭老年人的价值观、目标和偏好的一致程度。
This cohort study examines which patient and facility factors in the US Department of Veterans Affairs health care system are associated with dialysis approaches and outcomes. To what extent do dialysis use and mortality vary among older adults with incident kidney failure, and are these variations associated with patient or facility factors? In this cohort study of 8695 older adults with incident kidney failure, dialysis use varied widely across Veterans Affairs facilities with minimal variation in mortality. Most of the variation was associated with patient characteristics, and no correlation was found between the facility-level rate of dialysis use and mortality. Results of this study suggest that there is marked variation in dialysis use practices for older adults across Veterans Affairs facilities. Current guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities. To assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use. This cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System. Data analysis was conducted from August 1, 2019, to September 1, 2020. The primary exposure was the VA facility in which patients received most of their care before the onset of incident kidney failure defined as the first occurrence of either a sustained estimated glomerular filtration rate of less than 15 mL/min/1.73 m2 or the initiation of maintenance dialysis. The primary outcomes were dialysis use and mortality within 2 years of incident kidney failure. Median rate ratio was used to quantify facility-level variation, and variance partition coefficient was used to quantify the sources of unexplained variation. The cohort included 8695 older veterans with a mean (SD) age of 78.8 (7.5) years who were predominantly male (8573 [99%]) and White (6102 [70%]) individuals treated at 108 VA facilities. The observed frequency of dialysis use across facilities ranged from 25.0% to 81.4%, with a median (interquartile range [IQR]) rate of 51.7% (48.4%-60.0%). The observed frequency of mortality across facilities ranged from 27.2% to 60.0%, with a median (IQR) rate of 45.2% (41.2%-48.6%). The median rate ratio (adjusted for multiple patient and facility characteristics) was 1.40 for dialysis use and 1.08 for mortality. The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics. No correlation was found between dialysis use and mortality at the facility level (correlation coefficient = 0.03). This study found sizable variation in dialysis use for older adults that was poorly correlated with facility-level mortality rates and was not accounted for by differences in measured patient and facility characteristics. These findings suggest opportunities to improve the degree to which dialysis use practices align with the values, goals, and preferences of older adults with kidney failure.
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影响因子：
120.7
作者：
O'Hare, Ann M.;Rodriguez, Rudolph A.;Tamura, Manjula Kurella
通讯作者：
Tamura, Manjula Kurella
影响因子：
1.6
作者：
Sloan, Caroline E.;Zhong, Judy;Wang, Virginia
通讯作者：
Wang, Virginia
DOI：
10.2215/cjn.03930416
发表时间：
2017-01-01
影响因子：
9.8
作者：
Fuller, Douglas S.;Robinson, Bruce M.
通讯作者：
Robinson, Bruce M.
影响因子：
4
作者：
Heymans, Martijn W.;van Buuren, Stef;de Vet, Henrica C. W.
通讯作者：
de Vet, Henrica C. W.
影响因子：
19.6
作者：
Cook, W. L.;Jassal, S. V.
通讯作者：
Jassal, S. V.