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Figure.  Emergency Department (ED) Visits Associated With Hemodialysis
Emergency Department (ED) Visits Associated With Hemodialysis

LOS indicates length of stay.

Table.  Characteristics of Patients Who Made Emergency Department Visits for Hemodialysis, Stratified by Insurance Status
Characteristics of Patients Who Made Emergency Department Visits for Hemodialysis, Stratified by Insurance Status
1.
Nguyen  OK, Vazquez  MA, Charles  L,  et al.  Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease.  JAMA Intern Med. 2019;179(2):175-183. doi:10.1001/jamainternmed.2018.5866PubMedGoogle ScholarCrossref
2.
Hogan  AN, Fox  WR, Roppolo  LP, Suter  RE.  Emergent dialysis and its impact on quality of life in undocumented patients with end-stage renal disease.  Ethn Dis. 2017;27(1):39-44. doi:10.18865/ed.27.1.39PubMedGoogle ScholarCrossref
3.
Centers for Medicare & Medicaid Services. 2019 ICD-10 PCS: procedure coding system. https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS. Updated September 18, 2018. Accessed May 20, 2019.
4.
Texas Department of State Health Services. Texas health care information collection (THCIC). https://www.dshs.texas.gov/THCIC/. Published 2017. Accessed December 5, 2019.
5.
Texas Department of State Health Services. Public health regions. https://dshs.texas.gov/regions/. Updated December 16, 2019. Accessed June 26, 2019.
6.
Medicare Payment Advisory Commission. Report to the Congress: Medicare payment policy. http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf. Published March 2017. Accessed November 26, 2019.
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    Research Letter
    Emergency Medicine
    February 19, 2020

    Insurance Status and Emergency Department Visits Associated With Hemodialysis in Texas

    Author Affiliations
    • 1Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston
    JAMA Netw Open. 2020;3(2):e1921447. doi:10.1001/jamanetworkopen.2019.21447
    Introduction

    Patients with end-stage renal disease (ESRD) require regular hemodialysis (HD) treatment, which is nearly universally covered by Medicare in the United States.1 However, Medicare coverage is not available for individuals who are not US citizens or permanent residents. For many uninsured individuals with ESRD, intermittent dialysis through the emergency department (ED) is the sole treatment option.1 The system of accessing HD in the ED presents several major system-level challenges, including adding patient volume to overcrowded EDs, taxing hospital dialysis resources, and incurring substantial health care costs. Prior studies1,2 characterizing the health burden of ED visits for HD treatment by patients with ESRD were limited to a single region. We sought to characterize ED visits for HD by insured and uninsured patients in Texas.

    Methods

    We performed a cross-sectional analysis using the 2017 Texas Emergency Department Data Set. The Committee for the Protection of Human Subjects at The University of Texas Health Science Center at Houston approved the study and waived the need for informed consent because we used a preexisting set of deidentified data.

    We included all ED visits by patients aged 18 years or older. We identified ED visits for HD treatment according to International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes 5A1D00Z and 5A1D60Z to 5A1D90Z and Healthcare Common Procedure Coding System/Current Procedural Terminology codes G0257, 90935, 90937, 90957 to 90970, and 90999.3 To identify instances where the ED visit was most likely associated with HD for an acute indication, we limited the analysis to hospitalizations with a length of stay of 1 day or less. The primary exposure was insurance status. We classified Medicare, Medicaid, and commercial insurance as insured, and classified self-pay, charity, indigent, or unknown as uninsured. We determined the total number of ED visits for HD treatment, stratifying by insurance status. We converted reported hospital charges to estimated costs by using Healthcare Cost Utilization Project cost-to-charge ratios.4 We identified differences between insured and uninsured individuals using logistic regression analysis. All analyses were performed using Stata statistical software version 15.0 (StataCorp). Data analysis was performed from May 2019 to January 2020.

    Results

    There were a total of 8 392 693 adult ED visits; 6 968 438 visits had a length of stay of 1 day or less. Of all adult patients who visited the ED, 9786 (48.3%) were aged 18 to 44 years and 15 355 (60.9%) were female. Hemodialysis was associated with 33 829 ED visits, including 10 390 uninsured patients (incidence, 1.24 cases per 1000 adult ED visits; 95% CI, 1.22-1.26 cases per 1000 adult ED visits) and 23 439 insured patients (Figure). Most uninsured ED visits for HD originated from the Arlington (region 2/3; 6867 visits [66.1%]) and Houston (region 6/5S; 2123 visits [20.4%]) regions (Table).5 Uninsured patients requiring HD were more likely than insured patients to be younger (aged 18-44 years, 4158 [40.0%] vs 5628 [24.0%]), have white race (6870 [66.1%] vs 10 524 [44.9%]), and have Hispanic ethnicity (8893 [85.6%] vs 12 668 [54.0%]). There were no significant sex differences. Most patients requiring HD were discharged to home or home health care. Total hospital costs for uninsured HD visits were $21 837 047.40.

    Discussion

    We identified 10 390 ED visits for HD by uninsured patients in Texas in 2017. These ED visits resulted in more than $21.8 million in hospital costs. To our knowledge, these are the largest estimates of the statewide burden of uninsured HD.1,2 Regardless of some limitations, including the possibility of a regular HD source for these patients, our findings highlight the total number of HD-associated ED visits for which payment was not expected. In addition to increasing patient numbers and cost, uninsured HD-associated ED visits cause health care system strain because the determination of the need for HD often requires additional diagnostic tests, and individuals with ESRD not undergoing regular HD often present in clinical crisis,1 requiring significant inpatient stabilizing care in addition to HD. The observed regional variations in uninsured HD visits underscores the need for solutions that reflect differences in local populations and health resources. A visit to the ED for HD costs approximately $2000, as opposed to $250 for a scheduled outpatient session.6 Strategies such as providing scheduled outpatient HD for uninsured patients with ESRD1 and treating insured patients in after-hours outpatient settings could be a cost-effective alternative to ED visits for HD, potentially alleviating system burdens, saving health care resources, and achieving improved patient outcomes.

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    Article Information

    Accepted for Publication: December 19, 2019.

    Published: February 19, 2020. doi:10.1001/jamanetworkopen.2019.21447

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 West J et al. JAMA Network Open.

    Corresponding Author: Henry E. Wang, MD, MS, Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin St, 4th Flr, JJL, Houston, TX 77030 (henry.e.wang@uth.tmc.edu).

    Author Contributions: Ms West had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Molony, Robinson, Foringer, Wang.

    Acquisition, analysis, or interpretation of data: West, Chan, Molony, Foringer, Wang.

    Drafting of the manuscript: West, Molony, Foringer, Wang.

    Critical revision of the manuscript for important intellectual content: Chan, Molony, Robinson, Foringer, Wang.

    Statistical analysis: West, Chan, Molony, Foringer, Wang.

    Administrative, technical, or material support: Robinson, Wang.

    Supervision: Robinson, Foringer, Wang.

    Conflict of Interest Disclosures: Dr Foringer reported receiving personal fees from Otsuka Pharmaceuticals outside the submitted work. No other disclosures were reported.

    Funding/Support: The McGovern Medical School Dean’s Office and the Department of Emergency Medicine at The University of Texas Health Science Center at Houston provided scholarship funding to support this project.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Nguyen  OK, Vazquez  MA, Charles  L,  et al.  Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease.  JAMA Intern Med. 2019;179(2):175-183. doi:10.1001/jamainternmed.2018.5866PubMedGoogle ScholarCrossref
    2.
    Hogan  AN, Fox  WR, Roppolo  LP, Suter  RE.  Emergent dialysis and its impact on quality of life in undocumented patients with end-stage renal disease.  Ethn Dis. 2017;27(1):39-44. doi:10.18865/ed.27.1.39PubMedGoogle ScholarCrossref
    3.
    Centers for Medicare & Medicaid Services. 2019 ICD-10 PCS: procedure coding system. https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS. Updated September 18, 2018. Accessed May 20, 2019.
    4.
    Texas Department of State Health Services. Texas health care information collection (THCIC). https://www.dshs.texas.gov/THCIC/. Published 2017. Accessed December 5, 2019.
    5.
    Texas Department of State Health Services. Public health regions. https://dshs.texas.gov/regions/. Updated December 16, 2019. Accessed June 26, 2019.
    6.
    Medicare Payment Advisory Commission. Report to the Congress: Medicare payment policy. http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf. Published March 2017. Accessed November 26, 2019.
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