Dialysis Purgatory

This little article is not terribly generalizable and the results are eminently predictable – but this barbaric practice was my daily routine a couple years ago while working in Houston.

To received routinely scheduled dialysis, someone must, of course, pay for it. For those U.S. citizens without the means to pay, various federal mechanisms provide coverage. For non-U.S. citizens in this country without the means to pay, there is no external payor source – unless “necessary for the treatment of an emergency medical condition.” Therefore, many facilities simply restrict dialysis to non-citizen patients in extremis.

As you might expect, this is bad and bad for you. This retrospective cohort study follows 5-year survival and resource utilization, comparing those at hospitals where non-U.S. citizens could be eligible for scheduled dialysis with those at facilities where only emergency dialysis was available. The sample sizes are small – 169 in the “emergency-only” cohort and 42 in “standard” – but at 5 year follow-up, over half the “emergency-only” cohort had died, as compared with about 10% of the standard hemodialysis. Various statistical analyses and propensity matching further quantify the exact excess hazard of emergency dialysis.

Patients receiving emergency dialysis received, obviously, fewer sessions per month – 6.2 instead of 10.3. However, these savings are potentially offset by a ten-fold increase in acute care days, probably associated with those episodes of emergency dialysis. In the most morbid sense, unfortunately, total cost-savings probably favor the emergency dialysis cohort owing to the greatly increased mortality.

There are uncertainties and holes in these sorts of retrospective studies, particularly in a cohort whose deaths are potentially not documented in our national registries. The face validity for the overall findings is strong, however, even if the specific numbers are not reliable.

Regardless, just as a manner of respecting basic human decency, it is simple cruelty to layer this additional suffering onto the already miserable state of being dialysis-dependent. All feasible efforts should be made to provide access to regular dialysis, considering the burden on the health system infrastructure is likely similar.

“Association of Emergency-Only vs Standard Hemodialysis With Mortality and Health Care Use Among Undocumented Immigrants With End-stage Renal Disease”
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2665387

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