Scheduled versus Emergency-Only Dialysis in Undocumented Immigrants

Despite nearly universal coverage for scheduled dialysis in the United States via Medicare and Medicaid, in 40 of 50 states, undocumented immigrants receive emergency-only dialysis, defined as intermittent and provided in emergency departments (EDs) when patients present with imminently life-threatening indications including severe metabolic acidosis, hyperkalemia with impending fatal arrhythmia, uremia with altered sensorium,, or severe volume overload with hypoxia. As mandated under the 1986 Emergency Medical Treatment and Labor Act, patients receive enough dialysis to alleviate the life-threatening indications; they are instructed to return when symptoms indicating the need for dialysis arise again.

Compared with scheduled dialysis, there is an association between emergency-only dialysis and lower quality of life, physical stress, and psychosocial stress for patients and clinicians. Previous studies have provided limited data that suggest worse health outcomes and higher costs associated with emergency-only dialysis. There are few robust data available on the comparative effectiveness and costs of scheduled versus emergency-only dialysis.

Oanh Kieu Nguyen, MD, MAS, and colleagues recently conducted an observational cohort study to examine the comparative effectiveness in terms of mortality, healthcare utilization, and costs of scheduled versus emergency-only dialysis among undocumented immigrants with end-stage renal disease (ESRD). Results were reported online in JAMA Internal Medicine

[doi:10.1001/jamainternmed.2018.5866]

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Study data were available in 2014 when uninsured patients with ESRD in Dallas, Texas, became eligible to purchase off-exchange, private, commercial health insurance due to the universal ban on preexisting condition exclusions under the Affordable Care Act. The study population included 181 eligible adults who were receiving emergency-only dialysis in Dallas; the patients became newly eligible for private commercial insurance and applied in February 2015. Of the 181, 105 (65 men, 40 women, mean age, 45 years) received coverage and were enrolled in scheduled dialysis; for nonclinical reasons, 76 (38 men, 38 women, mean age, 52 years) were not enrolled in insurance and remained uninsured, receiving emergency-only dialysis.

The researchers examined data on eligible individuals during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015), with an intervening washout period (February 2015). All 181 individuals were undocumented immigrants; self-reported immigration data were collected from Parkland Hospital electronic health records.

Prior to enrollment, compared with the emergency-only dialysis group, those in the scheduled dialysis group were slightly younger (45.3 years vs 51.9 years), presented more frequently for dialysis (1.6 per week vs 1.1 per week), and had longer dialysis vintage (24 months vs 17 months). Those in the scheduled dialysis group also had biochemical abnormalities suggestive of more advanced kidney disease at baseline.

Rates of long-term vascular access were similar in the two groups (15% vs 17%), as were rates of diabetes (70%), hypertension (92%), and complications related to ESRD. Median follow-up for both groups was 12 months. At the end of follow-up, 73% of the scheduled dialysis group and 32% of the emergency-only dialysis group received an arteriovenous fistula or graft.

At 12 months, the overall unadjusted mortality rate in the scheduled dialysis group was 3% compared with 17% in the emergency-only dialysis group (P=.001), corresponding to an absolute risk reduction of 14% and a number needed to treat of seven. Also at 12 months, the adjusted hazard ratio (aHR) of death was nearly 5-fold higher among patients remaining on emergency-only dialysis; the two groups began to diverge at 3 months and continued to separate at 1 year of follow-up (aHR, 4.6; 95% confidence interval [CI], 1.2-18.2).

Patients in the scheduled group had a slightly higher adjusted rate of visits to the ED per month; the number of hospitalizations was similar between the two groups, but those in the scheduled group had fewer hospital days per 6 months compared with those in the emergency-only group.

Following enrollment, adjusted rates of visits to the ED, hospitalizations, and hospital days remained the same or slightly increased among patients in the emergency-only group; the rates were markedly reduced in the scheduled dialysis group, with 5.2 fewer ED visits per month (P<.001), 1.6 fewer hospitalizations per 6 months (P<.001), and 9.9 fewer hospital days per 6 months (P=.007), compared with the emergency-only group.

Adjusted worse-case scenario per person per month (PPPM) costs in the scheduled group were $10,806 compared with $8686 in the emergency-only group at baseline. Following enrollment, costs in the scheduled group decreased by an average of $4316 PPPM; costs for the emergency-only group increased by an average of $1452 PPPM. Net savings for those in the scheduled group were $5768 PPPM (95% CI, $3204 to $8332). The cost savings from reduction in healthcare utilizations exceeded increases from vascular access and scheduled dialysis.

There were steep declines in monthly healthcare utilization in the scheduled dialysis group immediately following initial enrollment and in the emergency-only group after the second open enrollment period when 92% of remaining individuals enrolled in scheduled dialysis.

The researchers cited several limitations to the study, including the possibility of residual confounding, the inability to account for expenditures on professional fees, outpatient medications, and ambulatory care not related to hemodialysis, and the possible underestimation of several potential downstream health system and societal benefits of scheduled dialysis.

In conclusion the researchers said, “Our study provides robust evidence of the clear health and societal benefits of providing scheduled dialysis to undocumented immigrants with ESRD, leveraging a unique opportunity for assessing the comparative effectiveness of the two strategies where a randomized clinical trial would be unethical and unfeasible. Given the quadruple win in terms of saving lives, saving money, improving quality of life, and reducing disparities with a more humane and evidence-based dialysis strategy for a highly vulnerable population, scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.”

Takeaway Points

  1. Scheduled dialysis is withheld from undocumented immigrants in 40 of the 50 states in the United States; the standard treatment for life-threatening complications of end-stage renal disease (ESRD) in that population is intermittent emergency-only dialysis in the emergency department.
  2. Researchers utilized data on undocumented immigrants with ESRD to examine the comparative effectiveness of scheduled versus emergency-only dialysis in terms of health outcomes, healthcare utilization, and costs.
  3.  Scheduled dialysis resulted in significantly reduced 1-year mortality, healthcare utilization, and costs compared with emergency-only dialysis.