Emergency-Only Dialysis Ups Deaths in Undocumented Immigrants

Diana Swift

December 19, 2017

Undocumented immigrants with end-stage renal disease (ESRD) are significantly more likely to die and to require longer hospital stays when they receive hemodialysis only as an emergency measure, reports a study published online December 18 in JAMA Internal Medicine.

The three-site observational study found the 5-year mortality rate was more than 14 times greater for those receiving emergency-only hemodialysis compared with a reference group receiving standard thrice-weekly hemodialysis. At 3 years, the mortality rate was almost five times greater.

"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," write Lilia Cervantes, MD, an internist at Denver Health in Colorado, and colleagues. There are approximately 6550 undocumented immigrants with ESRD in the United States, they write.

The authors say the greater mortality in patients receiving emergency-only hemodialysis is similar to that in patients receiving standard hemodialysis who miss treatment sessions.

The study sample consisted of 211 undocumented patients (mean age, 46.5 years) who began dialysis during 2007 to 2014. Of these, 169 were in an emergency-only hemodialysis group at two sites and 42 were in a group getting regularly scheduled hemodialysis at a third site. Most patients were male and Hispanic.

On average, regular-dialysis patients received 10.34 treatments compared with emergency-only patients' 6.26 treatments during a 30-day period. By year 3, 32 patients in the emergency group died vs 4 in the standard group; by year 5 this number had risen to 38 and 4 deaths, respectively.

At 3 years, the propensity score–adjusted mean relative hazard of mortality for patients receiving emergency-only dialysis was nearly five times greater than that for their standard-dialysis counterparts: 4.96 (95% confidence interval [CI], 0.93 - 26.45; P = .06). The adjusted mean 5-year relative hazard of mortality in the emergency-only care group was 14.13 (95% CI, 1.24 -161.00; P = .03). Similar findings in average 1-, 3-, and 5-year mortality emerged specifically in Hispanic patients.

In terms of hospitalization, the emergency-only group had approximately 10 times the number of acute care days (rate ratio, 9.81; 95% CI, 6.27 - 15.35; P < .001). Ambulatory care visits were three times fewer (rate ratio, 0.31; 95% CI, 0.21 - 0.46; P < .001). During 5-years follow-up, the expected number of bacteremia episodes did not differ significantly between groups, with an adjusted rate ratio for emergency-only patients of 1.64 (95% CI, 0.58 - 4.63).

In March of this year, Medscape published a commentary on previous research by Dr Cervantes' group describing the debilitating physical and psychosocial effects of policies that relegate undocumented immigrants with chronic kidney disease to emergent-only hemodialysis.

In a JAMA Internal Medicine audio interview, Dr Cervantes noted that access to emergency dialysis varies considerably across the country because each state  independently interprets federal language on what qualifies as emergency care. "Kidney patients must usually meet criteria for being critically ill," she said, adding that at some centers they may get only one emergency dialysis treatment and then have to reenter emergency care for follow-up treatment.

In some cases, state funding covers regular dialysis for undocumented immigrants, although most states provide emergency-only dialysis. The emergency-care option originated with the Emergency Medical Treatment and Labor Act amendment of 1986, which allows the use of federal Medicaid funds for services provided to undocumented immigrants if "such care and services…[are] necessary for the treatment of an emergency medical condition." 

As interpreted in some jurisdictions, that stipulation means many patients with ESRD receive dialysis only after exhibiting serious complications, such as uremia, hyperkalemia, hypertension, metabolic acidosis, and mental status changes.

Dr Cervantes' next study will examine cost issues associated with the emergency-only approach and its greater use of acute care, as well as the severe burden on the family, especially patients' children.

In the meantime, the authors urge states providing emergency-only hemodialysis to undocumented immigrants to address the human and economic impact of irregular care. "The life-and-death nature of emergency-only hemodialysis demands that we establish policies guiding care for undocumented immigrants with ESRD and balancing the many conflicting issues," they explain.

The work was supported by the Robert Wood Johnson Foundation, the Doris Duke Charitable Foundation, and the Constance B. Wofsy Distinguished Professorship at the University of California, San Francisco. The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online December 18, 2017. Abstract

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