Health Insurance Status Affects Dialysis Modality Choice

Each year, approximately 60,000 individuals <65 years of age develop end-stage renal disease (ESRD), requiring treatment with dialysis or kidney transplantation. Many patients are uninsured or covered by state-sponsored Medicaid at the onset of ESRD. While patients who are uninsured or covered by Medicaid may experience limited access to healthcare, access to dialysis care is generally available. Federal law provides Medicare coverage to patients with ESRD regardless of age, and most patients with ESRD qualify for Medicare by the fourth month of dialysis therapy. Following confirmation of qualification for Medicare, most patients are accepted for treatment at dialysis facilities.

Most patients receiving renal replacement therapy do not have access to a kidney donor and thus initiate either in-center hemodialysis or peritoneal dialysis; a third option at some centers is home dialysis. There are no data favoring outcomes with one modality over another; however, dialysis modality has a significant effect on a patient’s quality of life and overall treatment satisfaction. Younger patients with limited insurance may be particularly interested in peritoneal dialysis, which eliminates the need to travel to a hemodialysis center at least three times per week. Peritoneal dialysis is also less costly than in-center hemodialysis and patients receiving peritoneal dialysis are more likely to remain employed than those on in-center hemodialysis.

Rates of peritoneal dialysis in the United States are lower than in other countries. Barriers to use of peritoneal dialysis included inadequate patient education and financial disincentives. In addition, peritoneal dialysis requires surgical placement of a peritoneal dialysis catheter prior to therapy initiation, making choosing peritoneal dialysis difficult for patients who are uninsured or covered by Medicaid.

It is not known whether insurance status at ESRD onset influences choice of dialysis modality. Jose J. Perez, MD, and colleagues recently conducted a retrospective cohort analysis to examine whether use of peritoneal dialysis early in dialysis is affected by health insurance status and whether the effect of health insurance coverage changed following enactment of the ESRD Prospective Payment System (PPS) in 2011. Results of the analysis were reported in the American Journal of Kidney Diseases [2018;71(4):479-487].

The researchers utilized data from the US Renal Data System registry to select patients with incident ESRD who initiated in-center hemodialysis or peritoneal dialysis as their first modality in 2006 through 2012. Patients who died, recovered kidney function, or underwent kidney transplantation in the first 90 days of dialysis therapy were excluded. Patients were selected based on insurance criteria and age at initiation of dialysis therapy. Patients with limited insurance (i.e., uninsured or Medicaid only) were compared with patients with Medicare at onset of ESRD.

Included patients with limited insurance were 60 to 64 years of age and entered Medicare’s 90-day waiting period at ESRD onset. Included patients covered by Medicare at ESRD onset were 66 to 70 years of age.

There were 18,346 patients in the study cohort; of those, 45% had limited insurance. By the fourth month of dialysis, 2.7% of patients with limited insurance used peritoneal dialysis, compared with 4.3% of patients with Medicare (P<.001). Compared with patients covered by Medicare, patients in the limited insurance cohort were less likely to have received nephrology care prior to initiation of dialysis, were less likely to be women, and were less likely to have coronary artery disease, heart failure, cerebrovascular disease, peripheral vascular disease, lung disease, and immobility. They also had lower concentrations of serum hemoglobin and were less likely to be white.

There were 17,289 patients receiving in-center hemodialysis at the start of their fourth dialysis month; of those, 3.7% with limited insurance switched to peritoneal dialysis for the remainder of their first year of dialysis therapy, compared with 1.2% of patients with Medicare coverage at initiation of dialysis (P<.001). The analysis censored 23% and 33% of patients with limited insurance and Medicare, respectively, for death between days 90 and 365. The researchers also censored 0.6% and 0.3% of patients with limited insurance and Medicare, respectively, for kidney transplantation.

Results of multivariable analyses showed that patients with limited insurance at ESRD onset were less likely to receive peritoneal dialysis by their fourth dialysis month, compared with patients with Medicare (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71). This was an average predicted decrease of 2.4% (95% CI, 1.1%-3.7%) in the absolute adjusted probability of peritoneal use among patients with limited insurance. Following adjustment for differences in pre-ESRD nephrology care, the results were only slightly changed (OR, 0.52; 95% CI, 0.35-0.76).

When patients acquired Medicare after the third month of dialysis, those with limited insurance at onset of ESRD were significantly more likely to switch to peritoneal dialysis (hazard ratio, 2.9; 95% CI, 1.8-4.6). There were no substantial changes in those findings when analyses were conducted using patients’ first dialysis modality rather than dialysis modality at the start of the fourth dialysis month.

Regression analysis that included post-PPS interactions estimated that prior to enactment of the PPS, the odds of peritoneal use by the fourth dialysis month were 58% (95% CI, 37%-72%) lower among patients with limited insurance compared with patients with Medicare coverage at dialysis initiation. Following enactment of the PPS, the magnitude of reduction in odds became less pronounced (38%; 95% CI, 4%-60%) (P for interaction=.03).

The researchers cited some limitations to the study, including the observational design that created the possibility of selection bias, and the inability to use Medical Evidence Report to determine patient comorbid conditions.

“In summary, we found evidence that the use of peritoneal dialysis early in dialysis can be limited by insurance coverage that patients have when initiating dialysis therapy. Programs designed to educate physicians, patients, and other healthcare providers about home dialysis therapy and policies directed toward increasing patients’ access to providers involved in preparing patients for peritoneal dialysis therapy may give more patients the option to initiate peritoneal dialysis as their first kidney replacement modality.”

Takeaway Points

  1. Researchers conducted a retrospective cohort analysis to examine whether health insurance limitations affected the use of peritoneal dialysis among patients initiating dialysis therapy.
  2. Patients with limited insurance (no insurance or Medicaid) were compared with patients with Medicare at onset of end-stage renal disease.
  3. Following adjustments, patients with limited insurance had a 2.4% lower probability of peritoneal dialysis use by the fourth month of dialysis compared with patients with Medicare coverage at dialysis initiation.