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Predialysis Nephrology Care and Costs in Elderly Patients Initiating Dialysis

Stroupe, Kevin T. PhD*†‡; Fischer, Michael J. MD, MSPH*§¶; Kaufman, James S. MD∥**; O'Hare, Ann M. MD††‡‡; Sohn, Min-Woong PhD*§§; Browning, Margaret M. PhD*‡; Huo, Zhiping MS*; Hynes, Denise M. RN, PhD*‡¶

doi: 10.1097/MLR.0b013e31820192ba
Original Article

Background: Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization.

Methods: We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1–3 nephrology visits), moderate- (4–6 visits), and high-intensity (>6 visits) nephrology care during this time period.

Results: There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of $103,772, $96,390, $93,336, and $89,961 in total healthcare costs (P < 0.001), respectively. Greater intensity of predialysis nephrology care was associated with lower costs even among patients whose first predialysis nephrology visit was ≤3 months before dialysis initiation. Patients with greater predialysis nephrology care also had lower mortality rates during the year after dialysis initiation (43%, 38%, 28%, and 25%, respectively, P < 0.001).

Conclusions: Greater intensity of predialysis nephrology care was associated with fewer hospital days and lower total healthcare costs during the year after dialysis initiation, even though patients survived longer.

From the *Center for Management of Complex Chronic Care, Hines VA Hospital, Hines, IL; †Program in Health Services Research, Stritch School of Medicine, Loyola University Chicago, Maywood, IL; ‡VA Information Resource Center, Hines, IL; §Jesse Brown VA Medical Center, Chicago, IL; ¶Department of Medicine, University of Illinois, Chicago, IL; ∥VA Boston Healthcare System, Boston, MA; **Department of Medicine, Boston University, Boston, MA; ††VA Puget Sound Healthcare System, Seattle, WA; ‡‡Department of Medicine, University of Washington and Group Health Research Institute, Seattle, WA; and §§Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Supported by Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (VA HSR&D IIR 02–244 and IIR 20–016 [to K.T.S., D.M.H., and M.M.B.]; VA HSR&D Research Career Scientist Award [to D.M.H.]; VA HSR&D Career Development Award [to M.J.F.]) and the National Kidney Foundation of Illinois (to M.J.F.); NIH K23AG28980 (to A.M.O'H.).

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or Health Services Research and Development Service.

Reprints: Kevin T. Stroupe, PhD, Center for Management of Complex Chronic Care, Hines VA Hospital, 5000 South 5th Ave (151H) Bldg 1B260, Hines, IL 60141–5151. E-mail:

© 2011 Lippincott Williams & Wilkins, Inc.