Emergency department visits for hemodialysis by insurance status in the United States

Abstract

Objective: Many uninsured patients with end-stage kidney disease (ESKD) depend upon the emergency department (ED) for hemodialysis (HD). We sought to characterize ED visits for emergent HD by insurance status.

Methods: We performed a cross-sectional analysis of the 2017 Nationwide Emergency Department Sample, including ED visits by patients ≥18 years old with a length of stay ≤1 day and performance of HD. Insurance status determined by "insured" as Medicare, Medicaid, or commercial and "uninsured" as self-pay or charity.

Results: Of 118,034,396 adult ED visits, 235,988 were associated with HD: uninsured 62,503 (incidence 5.30 per 10,000, 95% confidence interval [CI]: 5.26-5.34) and insured 172,889 (incidence 14.65 per 10,000, 95% CI: 14.60-14.74). The south census region accounted for 89% of uninsured ED HD (odds ratio [OR] 31.55, 95% CI: 8.97-110.97). Compared to insured patients, uninsured ED HD patients were more likely to be younger (age 18-44, 37.6% vs 19.9%). The most common primary diagnosis for uninsured and insured ED HD patients was hypertensive chronic kidney disease (34.6% and 26.2%, respectively). Uninsured ED HD patients were less likely to be admitted (3.4% vs 36.0%, OR 0.06, 95% CI: 0.02-0.20). Most ED HD patients were discharged home (95.2% uninsured vs 57.6% insured). ED charges per visit were $5,992.32 for uninsured and $10,985.87 for insured ED HD patients.

Conclusions: Our findings highlight the health care burden of ED HD. Novel system approaches are needed for the management of uninsured and insured patients with ESKD.

Keywords: ESRD; chronic dialysis; chronic hemodialysis; dialysis; end‐stage kidney disease; end‐stage renal disease; hemodialysis.

FIGURE 1

Flow diagram of study inclusion criteria. A total of 144,814,803 emergency department visits were obtained from the State Inpatient Databases (SID) and State Emergency Department Databases (SEDD) for the 2017 calendar year. Only patients age ≤18 were included. We limited the analysis to ED visits with a LOS ≤1 day and then identified the occurrence of hemodialysis (HD). The total study population was 235,988 ED visits in which HD was provided. Finally, we characterized those visits as either uninsured or insured. There were 62,503 uninsured adult ED HD visits and 172,889 insured adult ED HD visits. Abbreviations: HD, hemodialysis; LOS, length of stay