Ethics Week - Emergent Dialysis for Undocumented Immigrants

Written by Clay Smith

Spoon Feed
Once insured, undocumented immigrants with end-stage renal disease (ESRD) who were then able to get scheduled vs emergency-only hemodialysis (HD) has a drop in 1-year mortality (NNT = 7) and saved almost $6,000/person/month in healthcare costs.

Why does this matter?
Undocumented immigrants with ESRD are not allowed scheduled HD in 40/50 US states and are only allowed HD for life threatening manifestations of ESRD. However, many are employed and contribute to the Medicare trust fund. Why cover this on Journal Feed? Because we are the ones who see them and advocate for them to get HD when they feel awful but may not yet have hyperkalemia yet. It is also an ED crowding issue. For more background, HD is expensive. All US citizens with ESRD on HD are enrolled in Medicare or Medicaid to cover the expenses. Undocumented immigrants are not eligible for either. Emergency HD rather than scheduled HD has typically been provided and is thought to be less expensive. This study asks about the true risk and cost to care for our undocumented patients with ESRD.

NNT = 7 to prevent one death - Does more need to be said?
This was a cohort of 181 undocumented immigrant patients with ESRD on HD, some of whom were eligible to purchase insurance after the ACA removed exclusion due to pre-existing conditions. Then non-profits stepped up to help cover the cost of the off-exchange commercial insurance. Of these, 105 received insurance and scheduled HD; 76 did not and received emergency HD only if life-threatening renal complications were present. One-year mortality was 3% among those receiving scheduled HD vs 17% for emergency-only HD, NNT = 7. Let me put that number in human terms. For every 7 of these patients insured, one patient per year didn’t die. Patients with scheduled HD had far fewer ED visits, hospitalizations, hospital days, and saved almost $6,000 per person per month. This seems like a no-brainer. In this health system alone, insuring all 181 patients would have saved $13 million per year. To be fair, healthcare economy wonks will point out that as people live longer, total costs may actually rise over time. This may be true. To sort this out would require a cost-utility analysis, which is outside the scope of this paper. To wrap up, assuming this study is correct, which I think it is, this seems like the right thing to do and appears to save money in the near term.

Source
Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease. JAMA Intern Med. 2019 Feb 1;179(2):175-183. doi: 10.1001/jamainternmed.2018.5866.

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Reviewed by Thomas Davis

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