JAMA Internal Medicine
Volume 178, Issue 2, 2018, Pages 188-195

Association of emergency-only vs standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease (Article) (Open Access)

Cervantes L.* , Tuot D. , Raghavan R. , Linas S. , Zoucha J. , Sweeney L. , Vangala C. , Hull M. , Camacho M. , Keniston A. , McCulloch C.E. , Grubbs V. , Kendrick J. , Powe N.R.
  • a Division of Nephrology, Department of Medicine, Denver Health, 777 Bannock, Mail Code 4000, Denver, CO 80204, United States, University of Colorado School of Medicine, Denver, United States
  • b Division of Nephrology, Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA, United States, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
  • c Department of Medicine, Harris Health, Houston, TX, United States, Baylor College of Medicine, Houston, TX, United States
  • d Division of Nephrology, Department of Medicine, Denver Health, 777 Bannock, Mail Code 4000, Denver, CO 80204, United States, University of Colorado School of Medicine, Denver, United States
  • e Division of Nephrology, Department of Medicine, Denver Health, 777 Bannock, Mail Code 4000, Denver, CO 80204, United States, University of Colorado School of Medicine, Denver, United States
  • f Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
  • g Baylor College of Medicine, Houston, TX, United States
  • h Division of Nephrology, Department of Medicine, Denver Health, 777 Bannock, Mail Code 4000, Denver, CO 80204, United States
  • i University of Colorado School of Medicine, Denver, United States
  • j Division of Nephrology, Department of Medicine, Denver Health, 777 Bannock, Mail Code 4000, Denver, CO 80204, United States, University of Colorado School of Medicine, Denver, United States
  • k Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
  • l Division of Nephrology, Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA, United States, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
  • m Division of Nephrology, Department of Medicine, Denver Health, 777 Bannock, Mail Code 4000, Denver, CO 80204, United States
  • n Division of Nephrology, Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA, United States, Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States

Abstract

IMPORTANCE: Undocumented immigrants with end-stage renal disease have variable access to hemodialysis in the United States despite evidence-based standards for frequency of dialysis care. OBJECTIVE: To determine whether mortality and health care use differs among undocumented immigrants who receive emergency-only hemodialysis vs standard hemodialysis (3 times weekly at a health care center). DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort studywas conducted of undocumented immigrants with incident end-stage renal disease who initiated emergency-only hemodialysis (Denver Health, Denver, Colorado, and Harris Health, Houston, Texas) or standard (Zuckerberg San Francisco General Hospital, San Francisco, California) hemodialysis between January 1, 2007, and July 15, 2014. EXPOSURES: Access to emergency-only hemodialysis vs standard hemodialysis. MAIN OUTCOMES AND MEASURES: The primary outcomewas mortality. Secondary outcomes were health care use (acute care days and ambulatory care visits) and rates of bacteremia. Outcomes were adjusted for propensity to undergo emergency hemodialysis vs standard hemodialysis. RESULTS: A total of 211 undocumented patients (86 women and 125 men; mean [SD] age, 46.5 [14.6] years; 42 from the standard hemodialysis group and 169 from the emergency-only hemodialysis group) initiated hemodialysis during the study period. Patients receiving standard hemodialysis were more likely to initiate hemodialysis with an arteriovenous fistula or graft and had higher albumin and hemoglobin levels than patients receiving emergency-only hemodialysis. Adjusting for propensity score, the mean 3-year relative hazard of mortality among patients who received emergency-only hemodialysis was nearly 5-fold (hazard ratio, 4.96; 95%CI, 0.93-26.45; P = .06) greater compared with patients who received standard hemodialysis. Mean 5-year relative hazard of mortality for patients who received emergency-only hemodialysis was more than 14-fold (hazard ratio, 14.13; 95%CI, 1.24-161.00; P = .03) higher than for those who received standard hemodialysis after adjustment for propensity score. The number of acute care days for patients who received emergency-only hemodialysis was 9.81 times (95%CI, 6.27-15.35; P < .001) the expected number of days for patients who had standard hemodialysis after adjustment for propensity score. Ambulatory care visits for patients who received emergency-only hemodialysis were 0.31 (95%CI, 0.21-0.46; P < .001) times less than the expected number of days for patients who received standard hemodialysis. CONCLUSIONS AND RELEVANCE: Undocumented immigrants with end-stage renal disease treated with emergency-only hemodialysis have higher mortality and spend more days in the hospital than those receiving standard hemodialysis. States and cities should consider offering standard hemodialysis to undocumented immigrants. © 2017 American Medical Association. All rights reserved.

Author Keywords

[No Keywords available]

Index Keywords

albumin end stage renal disease multicenter study health care policy survival rate hemoglobin blood level clinical trial Follow-Up Studies follow up human epidemiology trends middle aged controlled study time factor priority journal Time Factors ethnology albumin blood level procedures arteriovenous fistula Undocumented Immigrants bacteremia United States Humans undocumented immigrant male female hemodialysis risk factor Risk Factors Renal Dialysis outpatient department Article organization and management Retrospective Studies health care utilization major clinical study emergency care Kidney Failure, Chronic health care access propensity score outcome assessment cohort analysis hospital emergency service Emergency Service, Hospital hemoglobin retrospective study chronic kidney failure mortality Health Services Accessibility health care delivery
Link
https://www.scopus.com/inward/record.uri?eid=2-s2.0-85041687094&doi=10.1001%2fjamainternmed.2017.7039&partnerID=40&md5=40c64d006b3a3817820dce460bfcfb20
DOI: 10.1001/jamainternmed.2017.7039
ISSN: 21686106
Cited by: 49
Original Language: English