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      Association of Emergency-Only vs Standard Hemodialysis With Mortality and Health Care Use Among Undocumented Immigrants With End-stage Renal Disease

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          Abstract

          <div class="section"> <a class="named-anchor" id="ab-ioi170111-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e480">Importance</h5> <p id="d4179312e482">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. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e485">Objective</h5> <p id="d4179312e487">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). </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e490">Design, Setting, and Participants</h5> <p id="d4179312e492">A retrospective cohort study was 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. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e495">Exposures</h5> <p id="d4179312e497">Access to emergency-only hemodialysis vs standard hemodialysis.</p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e500">Main Outcomes and Measures</h5> <p id="d4179312e502">The primary outcome was 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. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e505">Results</h5> <p id="d4179312e507">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; <i>P</i> = .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; <i>P</i> = .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; <i>P</i> &lt; .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; <i>P</i> &lt; .001) times less than the expected number of days for patients who received standard hemodialysis. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e522">Conclusions and Relevance</h5> <p id="d4179312e524">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. </p> </div><p class="first" id="d4179312e527">This cohort study examines whether mortality and health care use differs among undocumented immigrants who receive standard hemodialysis (3 times weekly at a health care center) vs emergency-only hemodialysis. </p><div class="section"> <a class="named-anchor" id="ab-ioi170111-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e534">Question</h5> <p id="d4179312e536">Do mortality and health care use differ between undocumented immigrants with end-stage renal disease treated with emergency-only hemodialysis vs standard hemodialysis (3 times weekly)? </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e539">Findings</h5> <p id="d4179312e541">In this cohort study, mean 5-year mortality for patients who received emergency-only hemodialysis was more than 14-fold higher than for those who received standard hemodialysis. Patients who received emergency-only hemodialysis had more inpatient days but fewer outpatient clinic visits than those who received standard hemodialysis. </p> </div><div class="section"> <a class="named-anchor" id="ab-ioi170111-10"> <!-- named anchor --> </a> <h5 class="section-title" id="d4179312e544">Meaning</h5> <p id="d4179312e546">Availability of standard hemodialysis for undocumented immigrants could both save lives and reduce inpatient resource use, suggesting the need for a careful examination and potential change of existing health care policies. </p> </div>

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          Author and article information

          Journal
          JAMA Internal Medicine
          JAMA Intern Med
          American Medical Association (AMA)
          2168-6106
          February 01 2018
          February 01 2018
          : 178
          : 2
          : 188
          Article
          10.1001/jamainternmed.2017.7039
          5838789
          29255898
          © 2018

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