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Scheduled dialysis reduces mortality, costs in immigrants with ESRD

Compared with emergency-only dialysis, scheduled dialysis significantly reduced 1-year mortality, hospitalizations and costs among undocumented immigrants with end-stage renal disease, according to findings published in JAMA Internal Medicine.

“In 40 of 50 U.S. 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,” Oanh Kieu Nguyen, MD, MAS, from the department of internal medicine at the University of Texas Southwestern Medical Center, and colleagues wrote. “However, the comparative effectiveness of scheduled dialysis vs. emergency-only dialysis and the influence of treatment on health outcomes, utilization and costs is uncertain.”

Nguyen and colleagues conducted an observational study with a propensity score–adjusted, intention-to-treat approach to investigate the association of scheduled hemodialysis with health care outcomes, utilization and costs in undocumented immigrants with ESRD, compared with emergency-only hemodialysis.

The researchers enrolled 181 undocumented immigrants with ESRD who applied for private commercial health insurance in February 2015. Of those, 105 received coverage and scheduled dialysis (65 men; mean age, 45 years). The remaining 76 were not enrolled in insurance for nonclinical reasons and received emergency-only dialysis (38 men; mean age, 52 years).

Data were reviewed from 6 months prior to enrollment (baseline period, Aug. 1, 2014, to Jan. 31, 2015) to 1 year after enrollment (follow-up period, Mar. 1, 2015, to Feb. 29, 2016). There was a 1-month washout period (February 2015).

The researchers found a significant association between scheduled dialysis and reduced mortality (3% vs. 17%; absolute risk reduction, 14%; number needed to treat, 7; adjusted HR = 4.6; 95% CI, 1.2-18.2), compared with emergency-only hemodialysis.

Patients receiving scheduled dialysis had six fewer ED visits per month, approximately two fewer hospitalizations and 10 fewer hospital days per 6 months than those receiving emergency-only dialysis.

Additionally, adjusted costs were significantly lower with scheduled hemodialysis vs. emergency-only dialysis (–$4,316 vs. +$1,452 per person per month; difference-in-differences, –$5,768).

“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,” Nguyen and colleagues concluded. “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.” – by Alaina Tedesco

Disclosures: The authors report no relevant financial disclosures.