Employment among Patients Starting Dialysis in the United States

Abstract

Background and objectives: Patients with ESRD face significant challenges to remaining employed. It is unknown when in the course of kidney disease patients stop working.

Design, setting, participants, & measurements: We examined employment trends over time among patients ages 18-54 years old who initiated dialysis in the United States between 1996 and 2013 from a national ESRD registry. We compared unadjusted trends in employment at the start of dialysis and 6 months before ESRD and used linear probability models to estimate changes in employment over time after adjusting for patient characteristics and local unemployment rates in the general population. We also examined employment among selected vulnerable patient populations and changes in employment in the 6 months preceding dialysis initiation.

Results: Employment was low among patients starting dialysis throughout the study period at 23%-24%, and 38% of patients who were employed 6 months before ESRD stopped working by dialysis initiation. However, after adjusting for observed characteristics, the probability of employment increased over time; patients starting dialysis between 2008 and 2013 had a 4.7% (95% confidence interval, 4.3% to 5.1%) increase in the absolute probability of employment at the start of dialysis compared with patients starting dialysis between 1996 and 2001. Black and Hispanic patients were less likely to be employed than other patients starting dialysis, but this gap narrowed during the study period.

Conclusions: Although working-aged patients in the United States starting dialysis have experienced increases in the adjusted probability of employment over time, employment at the start of dialysis has remained low.

Keywords: African Americans; Economic Analysis; Employment; Epidemiology and outcomes; Hispanic Americans; Humans; Kidney Diseases; Kidney Failure, Chronic; Probability; Registries; Unemployment; United States; United States Renal Data System; chronic dialysis; clinical epidemiology; cyclo(Arg-Pro); end-stage renal disease; ethnicity; quality of life; renal dialysis.

Figure 1.

Unadjusted employment at dialysis initiation decreases slightly over time among all patients initiating dialysis, while increasing slightly among black and hispanic subpopulations. (A) Employment at dialysis initiation (all patients initiating dialysis. (B) Employment at the start of dialysis among vulnerable subpopulations.

Figure 2.

Employment 6 months before ESRD among all patients initiating dialysis decreased slightly over the study period.

Figure 3.

Predicted probabilities of employment at dialysis initiation increased over time after adjusting for changes in patient characteristics and employment trends in the general population. Note that predicted probabilities are derived from primary regression results. They were obtained separately for each calendar year on the basis of a scenario where all patients from the entire study population initiate dialysis in each calendar year. Estimates of the associations between calendar year of dialysis initiation and the probability of employment control for demographic and socioeconomic characteristics, patient health and comorbidities, and county-level rate of unemployment at the time of dialysis initiation. SEMs for predicted probabilities were estimated using the Δ-method.

Figure 4.

Predicted probabilities of employment 6 months before dialysis initiation and at dialysis initiation among those employed 6 months prior increase over time after adjusting for changes in patient characteristics and employment in the general population. Note that predicted probabilities are derived from primary regression results, where estimates of the association between calendar year of dialysis initiation and the probability of employment control for demographic and socioeconomic characteristics, patient health and comorbidities, and county-level unemployment rates at the time of dialysis initiation. SEMs for predicted probabilities were estimated using the Δ-method. Patients starting dialysis between 2008 and 2013 had an absolute increase of 6.6 percentage points in the adjusted probability of employment 6 months before the onset of dialysis compared with those starting dialysis between 1996 and 2001 (95% confidence interval, 6.2% to 7.0%; P<0.001). Patients who were employed 6 months before ESRD and who started dialysis between 2008 and 2013 had a 5.6 percentage points increase in the adjusted probability of employment at the start of dialysis compared with those who were employed 6 months before ESRD and who started dialysis between 1996 and 2001 (95% confidence interval, 4.9% to 6.3%; P<0.001) (Supplemental Tables 1 and 2).