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Associations between Demographic Factors and Provider Structures on Cost and Length of Stay for Hemodialysis Patients with Vascular Access Failure

Louis Brenner^*,,, Ajay K. Singh^*, Dennis Campbell^,, Frances Frei, and Wolfgang C. Winkelmayer^*,||

^* Renal Division; ^|| Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital and Harvard Medical School; Technology and Operations Management Unit; Accounting and Control Unit, Harvard Business School, Boston; and Renal and Transplant Business Units, Genzyme Corporation, Cambridge, Massachusetts

Address correspondence to: Dr. Louis Brenner, Renal Division, Brigham and Women’s Hospital, MRB-4, 75 Francis Street, Boston, MA 02115. Phone: 617-732-5951; Fax: 617-732-6392; E-mail: lbrenner{at}partners.org

Vascular access failure (VAF) is a major determinant of morbidity and cost for hemodialysis patients, but little is known about the care patterns and cost implications that are associated with VAF. A total of 952 episodes of VAF in 348 patients were identified using specific procedure codes. Demographic and care pattern characteristics were available as were detailed costs for each episode. The determinants of several important performance measures were evaluated: Cost per episode, inpatient versus outpatient treatment, and length of stay (LOS). Over 5 yr of study, the proportion of VAF episodes that were treated on an outpatient basis increased from 31 to 63%. Average costs of outpatient versus inpatient episodes were $1491 and $8265, respectively. Men were more likely to be treated as outpatients (odds ratio [OR] 1.56; 95% confidence interval [CI] 1.17 to 2.08), but once admitted, their LOS was longer (difference LOS +1.3; 95% CI +0.32 to +2.28) and more costly ($ +2603; 95% CI +632 to +4573). Nonblack, nonwhite patients were more likely to be treated as outpatients than were white patients (OR 2.07; 95% CI 1.27 to 3.36) and had shorter LOS once admitted (LOS –2.37; 95% CI –4.23 to –0.49). Compared with Medicare, non-Medicare case-managed insurance was associated with a higher likelihood of outpatient treatment (OR 1.40; 95% CI 1.01 to 1.94) for VAF and shorter LOS (LOS –1.36; 95% CI –2.48 to –0.24) and lower costs ($ –2742; 95% CI –5012 to –472) for inpatient treatment. It is concluded that gender and racial factors may influence VAF care. Over time, more VAF episodes are being treated in outpatient settings. Case management may lead to more outpatient treatment and shorter inpatient treatment of VAF.