Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease

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.

Figure 1.. Study Flow Diagram

Adults receiving emergency-only dialysis were consecutively referred to apply for private health insurance with coverage for scheduled dialysis services during a 2-week enrollment period. ^aIndividuals in the emergency-only group had the potential to enroll in scheduled dialysis during the second open enrollment from November 2015 to February 2016. For all analyses, these individuals were considered to be in the emergency-only group for the entirety of the follow-up period. ^bOf the 3 individuals who died between 9 and 12 months of follow-up, 1 was enrolled in scheduled dialysis and died shortly after enrollment.

Figure 2.. Survival Rates in Scheduled vs Emergency-Only Dialysis

Figure shows the Kaplan-Meier estimates of overall survival during the 12-month follow-up period. Individuals were censored at death (n = 16) or loss to follow-up (n = 20). The overall unadjusted mortality rate was 3% in the scheduled dialysis group (n = 3) compared with 17% in the emergency-only dialysis group (n = 13; P = .001), corresponding to an estimated absolute risk reduction of 14% and number needed to treat of 7 at 12 months. The adjusted hazard ratio for death for emergency-only vs scheduled dialysis was 4.6 (95% CI, 1.2-18.2; P = .03) by log-rank test.

Figure 3.. Monthly Trends in Utilization and Costs

Average monthly emergency department visits (A), hospitalizations (B), and costs (C). Bars indicate standard error. Enrollment was in February 2015 (washout). Grey dotted line marks the start of the second open enrollment (November 2015-February 2016), when 92% of those remaining on emergency-only dialysis enrolled.