Dialysis use for incident kidney failure in older veterans varies widely among Veterans Affairs (VA) facilities, but the differences do not correlate with facility-level mortality rates, according to a recent study.

The study included 8695 veterans with a mean age of 78.8 years treated at 108 VA facilities. All had stage 3 or 4 chronic kidney disease that progressed to kidney failure during January 1, 2011 to December 31, 2014. Of the patients who started dialysis, 83% started on hemodialysis rather than peritoneal dialysis.

After adjusting for patient and facility characteristics, the study found a 1.4-fold variation in dialysis use rates and 1.08-fold variation in mortality rates across VA facilities after adjusting for patient and facility characteristics, investigators led by Manjula Kurella Tamura, MD, MPH, of the Stanford University School of Medicine and Geriatric Research and Education Clinical Center at the Veterans Affairs Palo Alto Health Care System, in Palo Alto, California, reported online in JAMA Network Open.

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“We found sizeable unexplained variation in dialysis use practices among older adults across VA facilities that did not appear to be correlated with how sick the patients were,” they stated.

The observed frequency of dialysis use across the 108 VA facilities ranged from 25.0% to 81.4%, with a median rate of 51.7%, according to the investigators. The observed mortality rate ranged from 27.2% to 60.0%, with a median rate of 45.2%.

“The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics,” the authors wrote. 

The magnitude of between-facility variation in dialysis use was similar to the effect sizes for clinical characteristics such as pre-kidney failure nephrology care, cancer, and dementia, according to the investigators.

Nephrology care in the year before incident kidney failure was significantly associated with a 34% lower risk of dialysis use within 2 years. Patients who receive nephrology care “may be more compliant with treatment and may have better access to needed treatments and services, thus decreasing their rate of disease progression,” the authors stated.

Cancer and dementia diagnoses were significantly associated with a 20% and 40% decreased likelihood of starting dialysis, respectively.

Variation in dialysis use among patients with an estimated glomerular filtration rate of 15 mL/min/1.73 m2 accounted for some of the variation in dialysis use patterns, according to Dr Tamura and colleagues.


Bradshaw C, Thomas IC, Montez-Rath ME, et al. Facility-level variation in dialysis use and mortality among older veterans with incidence kidney failure. Published online January 15, 2021. JAMA Netw Open. doi:10.1001/jamanetworkopen.2020.34084