Associations of COVID-19 Outcomes with Dialysis Modalities and Settings

Abstract

How maintenance dialysis modality, dialysis setting, and residence in a nursing facility have jointly associated with coronavirus disease 2019 (COVID-19)-related outcomes in the United States is relevant to future viral outbreaks. Using Medicare claims, we determined the incidence of COVID-19-related infection, hospitalization, and death between March 15, 2020 and June 5, 2021. The exposure was one of five combinations of dialysis modality and care setting: in-facility hemodialysis without a recent history of skilled nursing facility care, in-facility hemodialysis with a recent history of skilled nursing facility care, hemodialysis in a skilled nursing facility, home hemodialysis, and (home) peritoneal dialysis. Patient-weeks were pooled to estimate the adjusted associations of event incidence with each dialysis modality/setting during four intervals in 2020-2021. Relative to in-facility hemodialysis without a recent history of skilled nursing facility care, home dialysis was associated with 36%-60% lower odds of all events during weeks 12-23 of 2020; 24%-37% lower odds of all events during weeks 24-37 of 2020; 20%-33% lower odds of infection and hospitalization during the winter of 2020-2021; and similar odds of all events thereafter. In contrast, exposure to skilled nursing facilities was associated with 570%-1140% higher odds of all events during spring of 2020, although excess risk attenuated as the pandemic transpired, especially among patients who received hemodialysis in skilled nursing facilities. In conclusion, home dialysis was associated with lower risks of COVID-19 diagnosis, hospitalization, and death until vaccines were available, whereas care in skilled nursing facilities was associated with higher risks.

Keywords: COVID-19; ESRD; United States Renal Data System.

Figure 1.

Overview of the study. COVID-19, coronavirus disease 2019; HD, hemodialysis; SNF, skilled nursing facility; USRDS, United States Renal Data System.

Figure 2.

Weekly incidence of COVID-19 diagnosis from epidemiologic week 12 of 2020 to week 22 of 2021 (March 15, 2020 to June 5, 2021). Patients undergoing in-facility HD without a recent history of SNF care are shown in black in both panels, patients on home HD are shown in red in the upper panel, patients performing home peritoneal dialysis (PD) are shown in blue in the upper panel, patients receiving in-facility HD with a recent history of SNF care are shown in purple in the lower panel, and patients receiving HD in an SNF are shown in green in the lower panel. Vertical lines separate the four intervals specified in risk models.

Figure 3.

Weekly incidence of COVID-19 hospitalization among patients undergoing in-facility HD without a recent history of SNF care (both panels), home HD (upper panel), home PD (upper panel), in-facility HD with a recent history of SNF care (lower panel), or HD in an SNF (lower panel) from epidemiologic week 12 of 2020 to week 22 of 2021 (March 15, 2020 to June 5, 2021). Vertical lines separate the four intervals specified in risk models.

Figure 4.

Weekly incidence of COVID-19 death among patients undergoing in-facility HD without a recent history of SNF care (both panels), home dialysis (upper panel), in-facility HD with a recent history of SNF care (lower panel), or HD in an SNF (lower panel) from epidemiologic week 12 of 2020 to week 22 of 2021 (March 15, 2020 to June 5, 2021). Vertical lines separate the four intervals specified in risk models.