Advocates for Evidence-Based Health Policy Speakers
Scheduled Dialysis for the Undocumented
Regular access to dialysis is a lifeline for patients with end stage renal disease (ESRD). Since 1972, Medicare has provided coverage for scheduled outpatient dialysis to U.S. citizens with ESRD. However, this coverage excludes the estimated 6500 undocumented immigrants with ESRD in the U.S., who are ineligible for federal assistance. In 40 states, undocumented patients must rely on emergency dialysis, presenting to emergency departments with life-threatening complications to receive care under the Emergency Medical Treatment and Active Labor Act. This two-tiered system comes at great cost to patients’ lives and the healthcare system.
A recent study by Nguyen and colleagues sheds light on the effects of expanding access to scheduled dialysis to this vulnerable population. The authors examined mortality and healthcare utilization of two cohorts of undocumented immigrants with ESRD, 105 who gained access to scheduled hemodialysis through private off-exchange insurance (with funding from a non-profit organization) compared to 76 who remained with emergency-only dialysis. The authors found that the cohort receiving scheduled dialysis had significantly lower mortality rate (3% vs. 17%, p=0.001), fewer emergency department visits (Difference-in-Difference -6.2, p<0.001) and fewer hospitalizations (Difference-in-Difference, -1.6, p<0.001) over one year compared to the emergency-only group. Yearly costs associated with scheduled dialysis totaled $72,000 less per person compared to emergency-only dialysis.
An important limitation of the study is potential confounding from the non-random assignment between the two groups. On baseline, the scheduled dialysis group had more frequent ED visits for dialysis and had been receiving dialysis for a longer timeframe than the emergency-only group. The more frequent hospital contact could have aided these patients in obtaining insurance and may reflect other differences between the two groups. The study’s difference-in-difference design provides robust results as it accounted for each group’s pre-intervention baseline.
Overall, this paper provides strong evidence for policymakers on the societal benefits of expanding access to scheduled dialysis for undocumented immigrants with ESRD. Important questions remain on how to design, finance, and implement these programs. It’s past time to turn evidence from real world interventions like this into impactful, life-saving policies across the country.
This Policy Prescriptions® review is written by Jeffrey Wang as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where he is a medical student.
Abstract
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.
PMID: 30575859
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