1
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: not found
      • Article: not found

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

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          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.

          Related collections

          Most cited references 25

          • Record: found
          • Abstract: found
          • Article: not found

          A randomized, controlled trial of early versus late initiation of dialysis.

          In clinical practice, there is considerable variation in the timing of the initiation of maintenance dialysis for patients with stage V chronic kidney disease, with a worldwide trend toward early initiation. In this study, conducted at 32 centers in Australia and New Zealand, we examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. We randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and 15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the Cockcroft-Gault equation) to planned initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause. Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis). In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. (Funded by the National Health and Medical Research Council of Australia and others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Cost analysis of ongoing care of patients with end-stage renal disease: the impact of dialysis modality and dialysis access.

            Care of patients with end-stage renal disease (ESRD) is important and resource intense. To enable ESRD programs to develop strategies for more cost-efficient care, an accurate estimate of the cost of caring for patients with ESRD is needed. The objective of our study is to develop an updated and accurate itemized description of costs and resources required to treat patients with ESRD on dialysis therapy and contrast differences in resources required for various dialysis modalities. One hundred sixty-six patients who had been on dialysis therapy for longer than 6 months and agreed to enrollment were followed up prospectively for 1 year. Detailed information on baseline patient characteristics, including comorbidity, was collected. Costs considered included those related to outpatient dialysis care, inpatient care, outpatient nondialysis care, and physician claims. We also estimated separately the cost of maintaining the dialysis access. Overall annual cost of care for in-center, satellite, and home/self-care hemodialysis and peritoneal dialysis were US $51,252 (95% confidence interval [CI], 47,680 to 54,824), $42,057 (95% CI, 39,523 to 44,592), $29,961 (95% CI, 21,252 to 38,670), and $26,959 (95% CI, 23,500 to 30,416), respectively (P < 0.001). After adjustment for the effect of other important predictors of cost, such as comorbidity, these differences persisted. Among patients treated with hemodialysis, the cost of vascular access-related care was lower by more than fivefold for patients who began the study period with a functioning native arteriovenous fistula compared with those treated with a permanent catheter or synthetic graft (P < 0.001). To maximize the efficiency with which care is provided to patients with ESRD, dialysis programs should encourage the use of home/self-care hemodialysis and peritoneal dialysis. Copyright 2002 by the National Kidney Foundation, Inc.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

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

              Importance 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. Objective 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). Design, Setting, and Participants 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. Exposures Access to emergency-only hemodialysis vs standard hemodialysis. Main Outcomes and Measures 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. Results 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; P  = .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; P  = .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; P  < .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; P  < .001) times less than the expected number of days for patients who received standard hemodialysis. Conclusions and Relevance 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. 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. Question 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)? Findings 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. Meaning 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.
                Bookmark

                Author and article information

                Journal
                JAMA Internal Medicine
                JAMA Intern Med
                American Medical Association (AMA)
                2168-6106
                December 21 2018
                Affiliations
                [1 ]Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
                [2 ]Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
                [3 ]Parkland Health & Hospital System, Dallas, Texas
                [4 ]Dallas Nephrology Associates, Dallas, Texas
                [5 ]RAND Corporation, Arlington, Virginia
                Article
                10.1001/jamainternmed.2018.5866
                6439652
                30575859
                © 2018

                Comments

                Comment on this article