Outcomes, Costs and Trends in Dialysis Timing in VA

提案标题：退伍军人中透析时机的结果、成本和趋势 PI：Paul L.Hebert，博士 项目摘要/摘要 目的：慢性肾脏病(CKD)是一种渐进性衰弱、高度 流行且代价不成比例的疾病。启动长期透析有 对患者的重大经济和生活质量影响以及 医疗保健系统和社会。透析的决定通常是基于拒绝 估计的肾小球滤过率(EGFR)水平和患者的症状 尿毒症，如疲劳和体重减轻，但透析的最佳时机不是很好 明白了。几乎没有证据可以评估转诊至透析的益处(如果有的话) 在较高水平的肾功能。这项研究的目的是解决这些影响 慢性肾脏疾病退伍军人早期透析与晚期透析的比较 弗吉尼亚州具体目标是1)确定早期透析的趋势是否在 国家水平也在退伍军人管理局内发现；2)估计退伍军人管理局的健康益处 较早开始透析的患者与较晚开始透析的患者相比；3)估计医疗费用 VA患者较早开始透析的成本。 研究计划：拟议的研究是对退伍军人管理局管理和 临床数据，并链接退伍军人事务部-美国肾脏数据系统(USRDS)数据。 方法：对于目标1，我们将确定发起透析的退伍军人和非退伍军人 从1995年到2007年，使用链接的退伍军人事务部-USRDS数据库。使用描述性统计 和回归分析，我们将比较早期开始透析的趋势(测量 透析时的EGFR)对VA和非VA患者进行比较，并探讨 退伍军人病学家内部和之间的EGFR和变异。对于目标2和目标3，我们将 使用2000至2006年间开始透析的VA患者的子集来估计 早期透析(EGFR&GT；7)与晚期透析的健康益处。使用以下组合 倾向分析、Logistic回归和工具变量分析，我们将 评估早期透析与晚期透析的死亡率、发病率和费用的差异 病人。

Proposal Title: Outcomes, Costs and Trends in Dialysis Timing in VA PI: Paul L. Hebert, PhD PROJECT SUMMARY/ABSTRACT Objectives: Chronic kidney disease (CKD) is a progressively debilitating, highly prevalent, and disproportionately costly disease. Initiation of long-term dialysis has significant financial and quality of life implications for the patient as well as costs to the health care system and society. The decision to dialyze is often based on declining levels of the estimated Glomerular Filtration Rate (eGFR) and patient symptoms of uremia, such as fatigue and weight loss, but optimal timing for dialysis is not well understood. There is little evidence to evaluate the benefits, if any, of referral to dialysis at higher levels of kidney function. The objectives of this study are to address the effects of early versus late dialysis for veterans with chronic kidney disease receiving care at the VA. Specific aims are to 1) determine if trends toward earlier dialysis apparent at the national level are also found within the VA; 2) estimate the health benefits for VA patients of earlier initiation of dialysis compared to later; and 3) estimate the medical cost of earlier initiation of dialysis for VA patients. Research Plan: The proposed study is a retrospective analysis of VA administrative and clinical data, and linked VA-U.S. Renal Data System (USRDS) data. Methodology: For Aim 1, we will identify veterans and non-veterans who initiated dialysis from 1995 to 2007 using the linked VA-USRDS databases. Using descriptive statistics and regression analysis, we will compare trends in early initiation of dialysis (measured by eGFR at dialysis) for VA versus non-VA patients, and explore regional variation in eGFR and variations within and between VA nephrologists. For Aims 2 and 3, we will use a subset of VA patients who initiated dialysis between 2000 and 2006 to estimate the health benefits of early dialysis (eGFR>7) vs. late dialysis. Using a combination of propensity analysis, logistic regression and instrumental variables analysis, we will assess differences in mortality, morbidity and costs for early-dialysis versus late-dialysis patients.