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J Am Soc Nephrol. 2020 Feb;31(2):424-433. doi: 10.1681/ASN.2019040417. Epub 2019 Dec 19.

Safety-Net Care for Maintenance Dialysis in the United States.

Author information

1
Selzman Institute for Kidney Health, Section of Nephrology, and kevin.erickson@bcm.edu.
2
Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas.
3
Baker Institute for Public Policy, Rice University, Houston, Texas.
4
Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California.
5
Selzman Institute for Kidney Health, Section of Nephrology, and.
6
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and.
7
Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California.

Abstract

BACKGROUND:

Although most American patients with ESKD become eligible for Medicare by their fourth month of dialysis, some never do. Information about where patients with limited health insurance receive maintenance dialysis has been lacking.

METHODS:

We identified patients initiating maintenance dialysis (2008-2015) from the US Renal Data System, defining patients as "safety-net reliant" if they were uninsured or had only Medicaid coverage at dialysis onset and had not qualified for Medicare by the fourth dialysis month. We examined four dialysis facility ownership categories according to for-profit/nonprofit status and ownership (chain versus independent). We assessed whether patients who were safety-net reliant were more likely to initiate dialysis at certain facility types. We also examined hospital-based affiliation.

RESULTS:

The proportion of patients <65 years initiating dialysis who were safety-net reliant increased significantly over time, from 11% to 14%; 73% of such patients started dialysis at for-profit/chain-owned facilities compared to 76% of all patients starting dialysis. Patients who were safety-net reliant had a 30% higher relative risk of initiating dialysis at nonprofit/independently owned versus for-profit/independently owned facilities (odds ratio, 1.30; 95% CI, 1.24 to 1.36); they had slightly lower relative risks of initiating dialysis at for-profit and non-profit chain-owned facilities, and were more likely to receive dialysis at hospital-based facilities. These findings primarily reflect increased likelihood of dialysis among patients without insurance at certain facility types.

CONCLUSIONS:

Although most patients who were safety-net reliant received care at for-profit/chain-owned facilities, they were disproportionately cared for at nonprofit/independently owned and hospital-based facilities. Ongoing loss of market share of nonprofit/independently owned outpatient dialysis facilities may affect safety net-reliant populations.

KEYWORDS:

United States Renal Data System; dialysis; economic impact; epidemiology and outcomes

PMID:
31857351
PMCID:
PMC7003304
[Available on 2021-02-01]
DOI:
10.1681/ASN.2019040417

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