Impact of the COVID-19 Pandemic on the Provision of Dialysis Service and Mortality in Veterans Receiving Maintenance Hemodialysis in the VA: An Interrupted Time-Series Analysis

Samir Patel; Eduardo A Trujillo Rivera; Venkatesh K Raman; Charles Faselis; Virginia Wang; Jeffrey C Fink; Jeffrey M Roseman; Charity J Morgan; Sijian Zhang; Helen M Sheriff; Michael S Heimall; Wen-Chih Wu; Qing Zeng-Treitler; Ali Ahmed

doi:10.1159/000532105

Impact of the COVID-19 Pandemic on the Provision of Dialysis Service and Mortality in Veterans Receiving Maintenance Hemodialysis in the VA: An Interrupted Time-Series Analysis

Am J Nephrol. 2023;54(11-12):508-515. doi: 10.1159/000532105. Epub 2023 Jul 31.

Authors

Samir Patel^{1

2}, Eduardo A Trujillo Rivera^{1

3}, Venkatesh K Raman^{1

4}, Charles Faselis^{1

2

5}, Virginia Wang^{6

7}, Jeffrey C Fink^{8

9}, Jeffrey M Roseman¹⁰, Charity J Morgan¹¹, Sijian Zhang¹, Helen M Sheriff^{1

12}, Michael S Heimall¹, Wen-Chih Wu^{13

14}, Qing Zeng-Treitler^{1

12}, Ali Ahmed^{1

2

4

12}

Affiliations

¹ Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, District of Columbia, USA.
² Department of Medicine, George Washington University, Washington, District of Columbia, USA.
³ Department of Pediatrics, Georgetown University, Washington, District of Columbia, USA.
⁴ Department of Medicine, Georgetown University, Washington, District of Columbia, USA.
⁵ Department of Medicine, Uniformed Services University, Washington, District of Columbia, USA.
⁶ Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA.
⁷ Departments of Population Health Sciences and Medicine, Duke University, Baltimore, Maryland, USA.
⁸ Veterans Affairs Medical Center, Baltimore, Maryland, USA.
⁹ Department of Medicine, University of Maryland, Baltimore, Maryland, USA.
¹⁰ Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹¹ Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹² Clinical Research and Leadership and Biomedical Informatics Center, George Washington University, Washington, District of Columbia, USA.
¹³ Medical service, Veterans Affairs Medical Center, Providence, Rhode Island, USA.
¹⁴ Department of Medicine, Brown University, Providence, Rhode Island, USA.

Abstract

Introduction: According to the US Renal Data System (USRDS), patients with end-stage kidney disease (ESKD) on maintenance dialysis had higher mortality during early COVID-19 pandemic. Less is known about the effect of the pandemic on the delivery of outpatient maintenance hemodialysis and its impact on death. We examined the effect of pandemic-related disruption on the delivery of dialysis treatment and mortality in patients with ESKD receiving maintenance hemodialysis in the Veterans Health Administration (VHA) facilities, the largest integrated national healthcare system in the USA.

Methods: Using national VHA electronic health records data, we identified 7,302 Veterans with ESKD who received outpatient maintenance hemodialysis in VHA healthcare facilities during the COVID-19 pandemic (February 1, 2020, to December 31, 2021). We estimated the average change in the number of hemodialysis treatments received and deaths per 1,000 patients per month during the pandemic by conducting interrupted time-series analyses. We used seasonal autoregressive moving average (SARMA) models, in which February 2020 was used as the conditional intercept and months thereafter as conditional slope. The models were adjusted for seasonal variations and trends in rates during the pre-pandemic period (January 1, 2007, to January 31, 2020).

Results: The number (95% CI) of hemodialysis treatments received per 1,000 patients per month during the pre-pandemic and pandemic periods were 12,670 (12,525-12,796) and 12,865 (12,729-13,002), respectively. Respective all-cause mortality rates (95% CI) were 17.1 (16.7-17.5) and 19.6 (18.5-20.7) per 1,000 patients per month. Findings from SARMA models demonstrate that there was no reduction in the dialysis treatments delivered during the pandemic (rate ratio: 0.999; 95% CI: 0.998-1.001), but there was a 2.3% (95% CI: 1.5-3.1%) increase in mortality. During the pandemic, the non-COVID hospitalization rate was 146 (95% CI: 143-149) per 1,000 patients per month, which was lower than the pre-pandemic rate of 175 (95% CI: 173-176). In contrast, there was evidence of higher use of telephone encounters during the pandemic (3,023; 95% CI: 2,957-3,089), compared with the pre-pandemic rate (1,282; 95% CI: 1,241-1,324).

Conclusions: We found no evidence that there was a disruption in the delivery of outpatient maintenance hemodialysis treatment in VHA facilities during the COVID-19 pandemic and that the modest rise in deaths during the pandemic is unlikely to be due to missed dialysis.

Keywords: COVID-19; Dialysis; Mortality; Veterans Affairs healthcare system.

MeSH terms

COVID-19* / epidemiology
Humans
Kidney Failure, Chronic*
Pandemics
Renal Dialysis
Retrospective Studies
Veterans*

Grants and funding

I01 HX002422/HX/HSRD VA/United States