Organization & Outcomes of Dialysis for Veterans with End Stage Renal Disease

描述（由申请人提供）： ESRD在VHA患者人群中的患病率高于一般美国人群，并与大量发病率、死亡率和VA医疗保健费用相关。对ESRD透析治疗的需求超过了VA有限的供应，要求VA通过VA费用基础计划从非VA提供者那里外包透析护理。基于费用的透析的VA成本一直以惊人的速度增长，但对VA或其退伍军人的价值却知之甚少。这引起了VA的担忧，特别是因为VA对其患者的外包护理几乎没有进行临床监督或问责。鉴于这些问题，VA正在探索新的护理和支付模式，以提高护理质量和降低成本。目前尚不清楚在不同环境下获得透析护理的退伍军人之间透析患者结局的差异。VA需要这些关于结果的比较信息，以了解与历史护理和支付模式相比，新模式是否提高了质量。由于接受慢性透析的退伍军人的保险范围和治疗环境的异质性，确定护理质量和最佳资源分配变得复杂。退伍军人可以在VAMC或社区环境中接受透析护理，由VA Fee Basis或Medicare ESRD计划资助。努力提高VA透析护理的质量和成本是进一步复杂的VA和医疗保险独立实施的透析治疗，这可能共同合谋改变退伍军人在一个系统或另一个接受透析护理的激励结构最近的支付政策。确定这些潜在的决定因素，塑造退伍军人的护理选择，需要调整混淆比较结果评估，并了解政策变化对退伍军人护理的影响。本研究的目的是检查退伍军人慢性透析护理设置的比较有效性。通过合并VA和Medicare管理和索赔数据，本研究将确定2008-2012年发生ESRD事件的退伍军人的全国样本，以（1）检查退伍军人在VA资助的VAMC诊所、VA资助的费用基础和Medicare设置中的透析利用程度以及在透析设置之间转换的患者比例;（2）确定与退伍军人选择透析设置相关的患者和VAMC水平特征;（3）检查全因和特定原因的住院率和死亡率是否因透析设置而异。

DESCRIPTION (provided by applicant): ESRD is more prevalent among the VHA patient population than the general US population and is associated with substantial morbidity, mortality, and VA health care costs. Demand for dialysis treatment for ESRD exceeds VA's limited supply, requiring VA to outsource dialysis care from non-VA providers through the VA Fee Basis program. VA costs for Fee Basis dialysis have been increasing at an astonishing rate with little understanding of its value to VA or its Veterans This has prompted concerns in VA, particularly because VA exerts little clinical oversight or accountability for outsourced care for its patients. In light of these concerns, VA is exploring ne care and payment models to improve quality of care and reduce costs. It remains unclear how dialysis patient outcomes differ between Veterans obtaining dialysis care in various settings. VA needs this comparative information about outcomes to understand if new models are improving quality compared to historic care and payment models. Determination of quality of care and optimal resource allocation is complicated by heterogeneity in insurance coverage and treatment settings among Veterans receiving chronic dialysis. Veterans can receive dialysis care at VAMC or in community settings that is financed either by VA Fee Basis or by the Medicare ESRD program. Efforts to improve the quality and cost of VA dialysis care is further complicated by recent payment policies that VA and Medicare have independently implemented for dialysis treatment, which may have together conspired to change the incentive structure for Veterans' receiving dialysis care in one system or another. Identifying these potential determinants shaping Veteran's choice of care is needed to adjust for confounding in comparative outcomes assessment and to understand the implications of policy changes on Veteran care. The objectives of this study are to examine the comparative effectiveness of Veterans' chronic dialysis care settings. Through a merge of VA and Medicare administrative and claims data, this study will identify a national sample of incident ESRD Veterans in 2008-2012 to (1) examine the extent of Veterans' dialysis utilization in VA-financed VAMC clinics, VA-financed Fee Basis, and Medicare settings and the proportion of patients switching between dialysis settings; (2) identify patient and VAMC-level characteristics associated with Veterans' choice of dialysis setting; and (3) examine whether all-cause and cause-specific hospitalization and mortality rates vary by dialysis setting.