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Insurance-related disparities in dialysis linked with risk of vascular access infections
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According to recently published results, insurance-related disparities in the use of arteriovenous fistulas and grafts in patients who underwent dialysis continued through the fourth month of dialysis and may not fully correct after patients obtain Medicare coverage. In addition, these disparities were linked to greater risk of vascular access infections.
“Patients starting hemodialysis must wait for up to 3 months before they qualify for Medicare,” Eugene Lin, MD, MS, told Healio.com/Nephrology. “This short period of time without insurance is associated with delays in the placement and use of arteriovenous fistulas and grafts when compared to patients with Medicaid or Medicare on the first day of dialysis. Even though the period of time without insurance is short-lived, the disparity in arteriovenous fistula and graft use continues to persist through the first year of hemodialysis. Compared to the Medicare population, the delay in fistula and graft use was associated with increased infections in the uninsured.”
Lin and colleagues used a national registry in a retrospective cohort study to compare uninsured patients with ESKD who began in-center hemodialysis with a central venous catheter with similar patients with Medicare or Medicaid. Investigators assessed whether insurance status at dialysis start impacted the likelihood of a patient switching to dialysis through an arteriovenous fistula or graft and hospitalizations involving a vascular access infection.
Results showed patients with Medicare or Medicaid compared with those who were uninsured were more likely to switch to an arteriovenous fistula or graft by the fourth dialysis month. Investigators noted after all patients had obtained Medicare in their fourth dialysis month, no differences were seen in the rates of patients who switch to arteriovenous fistula or graft. At the start of dialysis, patients with Medicare had fewer hospitalizations that involved vascular access in dialysis months 4 to 12. – by Monica Jaramillo
Disclosure s : The authors report no relevant financial disclosures.
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Michael Allon, MD
Uninsured patients who initiate hemodialysis prior to age 65 years ultimately qualify for Medicare coverage, but there is a 3-month lag before this occurs. Any medical care provided during the first 3 months of dialysis is not reimbursed. Clearly, this policy creates delays in the placement of a vascular access, as surgeons are reluctant to perform surgery for free.
Lin and colleagues quantified the consequences of lack of health insurance in the first 3 months of hemodialysis on the likelihood of achieving a permanent vascular access. They compared two patient cohorts without pre-ESRD nephrology follow-up who initiated dialysis with a central vein catheter (CVC) between 2010 and 2013: patients aged 65 to 69 years with prior Medicare coverage and uninsured patients aged 60 to 64 years.
The likelihood of using an arteriovenous fistula (AVF) or arteriovenous graft (AVG) by the fourth dialysis month was lower in the uninsured patient group (11% vs 16%). This difference was associated with a higher likelihood of hospitalization due to vascular access infection in the uninsured patient cohort. Among those patients who were still catheter-dependent at the end of their fourth month on dialysis (when the uninsured patients qualified for Medicare), there was no difference in the time to switching to AVF or AVG use over the ensuing 8 months.
These findings suggest that a change in Medicare policy to establish coverage immediately upon dialysis initiation would increase early AVF use, but the benefit would be modest. There are many other obstacles to achieving timely AVF use. A recent DOPPS publication reported a median time of 82 days from AVF creation to first successful use. In other words, only about half would be used within 3 months. A substantial proportion of new AVFs fail to mature, and many require surgical or percutaneous interventions to promote their maturation. Even among insured patients with 1-year pre-ESRD nephrology follow-up, only 60% undergo access surgery before dialysis initiation. Moreover, among patients with pre-ESRD AVF surgery, about 50% still initiate dialysis with a CVC.
Clearly, the fragmented nature of medical care is a huge contributor to poor vascular access outcomes.
Division of Nephrology
University of Alabama at Birmingham
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Lin E, et al. Clin J Am Soc Nephrol.2018;doi:10.2215/CJN.06660518.
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