Uninsured Patients Experience Delays in Obtaining Arteriovenous Access for Hemodialysis

By Will Boggs MD

November 05, 2018

NEW YORK (Reuters Health) - Uninsured patients who start in-center hemodialysis with a central venous catheter are less likely than those already on Medicare or Medicaid to obtain arteriovenous fistulas (AVF) or grafts (AVG) by their fourth month of dialysis, when they become Medicare eligible, according to a new study.

"Timing of dialysis access placement and use is important, and even short delays in arteriovenous fistula or graft use might lead to long-term negative consequences," said Dr. Eugene Lin from Keck School of Medicine at the University of Southern California, in Los Angeles.

"Although we expected to find short-term disparities in arteriovenous fistula and graft use associated with the 3-month waiting period without insurance, we were surprised that differences in fistula and graft use persisted through the first year of dialysis even after the uninsured enrolled in Medicare," Dr. Lin told Reuters Health by email.

More than 60% of U.S. hemodialysis patients receive dialysis through an AVF, but only 20% initiate dialysis with an AVF or AVG, a rate lower than other developed countries, Dr. Lin and colleagues point out in Clinical Journal of the American Society of Nephrology online, online November 1.

As many as 20% of U.S. adults under age 65 who develop end-stage kidney disease (ESKD) are uninsured, and these patients are even less likely to initiate dialysis with an AVF or AVG, the authors add. Medicare covers dialysis, but patients without Medicare at the onset of ESKD must wait three months before they become Medicare-eligible based on having ESKD. This wait could result in disparities in AVF and AVG use.

The researchers used data from the United States Renal Data System (USRDS), the 2010 census and the 2012 American Community Survey to examine whether uninsured patients at the start of dialysis experience persistent delays in AVF and AVG use.

After adjustment for other factors, patients 65-69 years old with Medicare who initiated dialysis using a central venous catheter were 63% (95% confidence interval, 1.14 to 2.43) more likely than uninsured patients 60-64 years old to use an AVF or AVG by their fourth dialysis month.

Similarly, patients under 65 years old with Medicaid who initiated dialysis using a central venous catheter were 23% (95% CI, 1.12 to 1.38) more likely than uninsured patients to use an AVF or AVG by their fourth dialysis month.

"Although the absolute differences in early AVF and AVG use were modest (5% and 2% unadjusted in the Medicare and Medicaid comparisons, respectively), the relative increases could translate into more substantial gains in younger populations more likely to receive AVF and AVGs," the researchers note.

By the end of month 12, patients with Medicare at the start of dialysis were still 11% more likely than previously uninsured patients to use an AVF or AVG, but there was no longer a significant difference between patients with Medicaid at the start of dialysis and previously uninsured patients.

Compared with uninsured patients, patients with Medicare at the start of dialysis had a 40% lower likelihood of hospitalization involving a vascular-access infection between dialysis months four and 12, but no difference in the likelihood of hospitalization with any infection.

In contrast, Medicaid patients were 21% more likely to be hospitalized with any infection (but not with a vascular access infection) than were uninsured patients, a significant difference.

"Coverage for vascular access care among the uninsured population before the fourth month of dialysis could yield increased AVF and AVG use and lead to improvements in patient health and healthcare costs," the researchers conclude.

"A change that extends Medicare eligibility to the first 90 days of dialysis would likely require legislation from Congress," Dr. Lin said. "Previous attempts at bridging this gap were met with opposition, and it is likely that any future attempts would face similar opposition if viewed as an attempt to expand a federal entitlement program."

"Right now," he said, "patients without insurance must either pay out of pocket, incur debt, or receive subsidized care during this 3-month period."

Dr. Osman Ahmed of the University of Chicago, who recently evaluated hemodialysis-access maintenance in the Medicare population, told Reuters Health by email, "Continued research and investigation into this issue will hopefully continue to shed light on this gap in care and potential opportunity for improved access to dialysis care. Specifically, continued study utilizing national databases is needed to demonstrate actual cost-savings by allowing earlier access to insurance for our uninsured dialysis patients. At present, it is apparent from this study that uninsured patients are at a real disadvantage with respect to access to safer and more reliable methods of hemodialysis (i.e., AVF/AVG)."

"The authors are to be commended for highlighting this opportunity to improve care for patients with end-stage kidney disease," he said. "In the era of 'big data,' continued investigation through national databases such as the USRDS will help identify important trends in healthcare that can be used to both improve quality of care delivered to patients and decrease spending."

SOURCE: https://bit.ly/2SEW20u

Clin J Am Soc Nephrol 2018.

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