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Original Investigation
December 21, 2018

Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
  • 3Parkland Health & Hospital System, Dallas, Texas
  • 4Dallas Nephrology Associates, Dallas, Texas
  • 5RAND Corporation, Arlington, Virginia
JAMA Intern Med. Published online December 21, 2018. doi:10.1001/jamainternmed.2018.5866
Key Points

Question  What is the association of scheduled vs emergency-only hemodialysis with health care outcomes and costs in undocumented immigrants with end-stage renal disease?

Findings  In this cohort study of 181 adults, individuals receiving scheduled vs emergency-only dialysis had a 1-year mortality rate of 3% vs 17%, 6 fewer emergency department visits per month, 1.5 fewer hospitalizations, 10 fewer hospital days per 6 months, and incurred $5768 less in health care costs per month.

Meaning  Compared with emergency-only dialysis, scheduled dialysis was associated with reduced mortality, health care utilization, and costs during a 1-year follow-up period and should be the universal standard of care for all individuals with end-stage renal disease in the United States.

Abstract

Importance  In 40 of 50 US states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease (ESRD); instead, they receive intermittent emergency-only dialysis to treat life-threatening manifestations of ESRD. However, the comparative effectiveness of scheduled dialysis vs emergency-only dialysis and the influence of treatment on health outcomes, utilization, and costs is uncertain.

Objective  To compare the effectiveness of scheduled vs emergency-only dialysis with regard to health outcomes, utilization, and costs in undocumented immigrants with ESRD.

Design, Setting, and Participants  Observational cohort study of 181 eligible adults with ESRD receiving emergency-only dialysis in Dallas, Texas, who became newly eligible and applied for private commercial health insurance in February 2015; 105 received coverage and were enrolled in scheduled dialysis; 76 were not enrolled in insurance for nonclinical reasons (eg, lack of capacity at a participating outpatient dialysis center) and remained uninsured, receiving emergency-only dialysis. We examined data on eligible persons during a 6-month period prior to enrollment (baseline period, August 1, 2014-January 31, 2015) until 12 months after enrollment (follow-up period, March 1, 2015-February 29, 2016), with an intervening 1-month washout period (February 2015). All participants were undocumented immigrants; self-reported data on immigration status was collected from Parkland Hospital electronic health records.

Exposures  Enrollment in private health insurance coverage and scheduled dialysis.

Main Outcomes and Measures  We used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score–adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs.

Results  Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis. Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (−5.2 vs +1.1 visits/mo; DiD, −6.2; P < .001), adjusted hospitalizations (−2.1 vs −0.5 hospitalizations/6 months; DiD, −1.6; P < .001), adjusted hospital days (−9.2 vs +0.8 days/6 months; DiD, −9.9; P = .007), and adjusted costs (−$4316 vs +$1452 per person per month; DiD, −$5768; P < .001).

Conclusions and Relevance  In this study, scheduled dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.

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