Not all kidney patients treated equal: Differences in care for patients beginning on dialysis

Kidney disease patients insured by some federally sponsored national health care organisations are more likely to undergo an important predialysis procedure than patients with other types of insurance, according to a study appearing in an upcoming issue of the Journal of the American Society Nephrology (JASN). The results may provide insights into ways to improve kidney-related care for patients before they go on dialysis.

For patients whose kidneys no longer work, haemodialysis performs the work of the kidneys. Experts recommend creating an arteriovenous fistula (AVF), to connect a vein and artery and allow access to the vascular system. An AVF provides a long-lasting site through which blood can be removed and returned during the dialysis procedure, which patients must undergo 3-4 times per week.

While AVF use for haemodialysis access is safe, cost-effective, and associated with improved survival in kidney disease patients, only a minority of US patients start haemodialysis with an AVF (13.7% in 2008).

Frank Hurst, MD (Walter Reed Army Medical Centre and F. Edward Hebert School of Medicine) and his colleagues evaluated the use of AVFs in federally sponsored national health care organisations such as the Departments of Veterans Affairs (DVA) and Department of Defence (DoD). Dr Hurst and his team searched the United States Renal Data System (USRDS) database to identify patients who initiated haemodialysis between 2005 and 2006. They found that patients who received predialysis kidney care were 10 times as likely to begin dialysis with an AVF compared with patients who did not receive such care. Patients with DVA/DoD insurance were 40% more likely to initiate dialysis with an AVF compared with patients with other types of insurance. Specifically, 27.2% of patients with DVA/DoD insurance initiated haemodialysis with an AVF, compared with 18.5% of patients reporting employer-group insurance, 16.7% of patients with 'Other' insurance, 15.6% of patients with Medicare, 13.0% of patients with Medicaid, and 8.2% of patients who reported no insurance. The analysis also revealed that patients who initiated haemodialysis at a DoD facility were twice as likely to use an AVF.

Experts are attempting to increase the use of AVFs through initiatives such as the Fistula First Breakthrough Coalition, whereby the Centres for Medicare and Medicaid Services, End Stage Renal Disease Networks, and the entire kidney community are working together to ensure that every suitable patient will receive the most optimal form of vascular access. Dr Hurst's findings show that despite these efforts, AVF use is still highly dependent upon a patient's type of health insurance prior to the initiation of dialysis.

'Further study of these federal systems may identify practices that could improve processes of care across healthcare systems to increase the number of patients who initiate haemodialysis with an AVF,' the authors wrote. They added that while AVF use is more frequent in DVA/DoD patients, the proportion of these patients who initiate haemodialysis with an AVF is still far too low.

Study co-authors include Kevin Abbott, MD (Walter Reed Army Medical Centre and F. Edward Hebert School of Medicine); Dominic Raj, MD (George Washington University); Mahesh Krishnan, MD (Davita Clinical Research); Carlos Palant, MD (Washington DC VA Medical Centre and George Washington University School of Medicine); Lawrence Agodoa, MD (National Institutes of Health); and Rahul Jindal, D, PhD (George Washington University, Walter Reed Army Medical Centre, and Brookdale University Medical Centre).

In an accompanying editorial, Steve Schwab, MD and Kennard Brown, PhD (University of Tennessee Health Science Centre) expressed dismay that AVF placement before dialysis, which requires treatment by both a nephrologist and a vascular surgeon, is not covered by Medicare, which supports most coverage for dialysis. 'We now have a public policy that treats a catastrophic illness such as renal failure but does not act to prevent or ameliorate that catastrophe earlier,' they wrote. The authors advocate for amending policy guidelines so that patients can benefit from seeing specialists early in the course of their disease.