TY - JOUR
T1 - Association of Scheduled vs Emergency-Only Dialysis with Health Outcomes and Costs in Undocumented Immigrants with End-stage Renal Disease
AU - Nguyen, Oanh K
AU - Vazquez, Miguel A.
AU - Charles, Lakeesha
AU - Berger, Joseph R.
AU - Quiñones, Henry
AU - Fuquay, Richard
AU - Sanders, Joanne M.
AU - Kapinos, Kandice A.
AU - Halm, Ethan A
AU - Makam, Anil N
N1 - Funding Information:
publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award numbers KL2TR001103 and UL1TR001105. Dr Nguyen also received funding support from the National Heart, Lung, and Blood Institute (NHLBI 1K23HL133441); Dr Halm received funding support from the Agency for Healthcare Research and Quality (AHRQ R24 HS022418); and Dr Makam received funding support from the National Institute on Aging (NIA 5K23AG052603).
Funding Information:
In this issue of JAMA Internal Medicine, Nguyen et al2 report that not providing scheduled, standard-of-care dialysis to undocumented people with end-stage renal disease (ESRD) comes with alarming consequences. Nguyen et al2 compared undocumented patients in Dallas, Texas, who received emergency-only dialysis, the only option available for undocumented people with ESRD in 40 states, with those who received standard-of-care, scheduled dialysis. Scheduled dialysis became newly available to undocumented people through an off-exchange private insurance plan funded by local charitable premium assistance. Nguyen et al2 found that for every 7 patients receiving emergency-only dialysis, 1 more will die every year compared with those receiving scheduled dialysis.
PY - 2019/2
Y1 - 2019/2
N2 - Importance: In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain. Objective: To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD. Design, Setting, and Participants: Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records. Exposures: Enrollment in private health insurance coverage and scheduled dialysis. Main Outcomes and Measures: We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs. Results: Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P =.001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P =.03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P <.001), adjusted hospitalizations (-2.1 vs -0.5 hospitalizations/6 months; DiD, -1.6; P <.001), adjusted hospital days (-9.2 vs +0.8 days/6 months; DiD, -9.9; P =.007), and adjusted costs (-$4316 vs +$1452 per person per month; DiD, -$5768; P <.001). Conclusions and Relevance: In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States..
AB - Importance: In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain. Objective: To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD. Design, Setting, and Participants: Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records. Exposures: Enrollment in private health insurance coverage and scheduled dialysis. Main Outcomes and Measures: We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score-adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs. Results: Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P =.001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P =.03), adjusted emergency department visits (-5.2 vs +1.1 visits/mo; DiD, -6.2; P <.001), adjusted hospitalizations (-2.1 vs -0.5 hospitalizations/6 months; DiD, -1.6; P <.001), adjusted hospital days (-9.2 vs +0.8 days/6 months; DiD, -9.9; P =.007), and adjusted costs (-$4316 vs +$1452 per person per month; DiD, -$5768; P <.001). Conclusions and Relevance: In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States..
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U2 - 10.1001/jamainternmed.2018.5866
DO - 10.1001/jamainternmed.2018.5866
M3 - Article
C2 - 30575859
AN - SCOPUS:85059148170
VL - 179
SP - 175
EP - 183
JO - JAMA Internal Medicine
JF - JAMA Internal Medicine
SN - 2168-6106
IS - 2
ER -