A unique opportunity made it feasible for uninsured patients with end-stage renal disease (ESRD) who received emergency-only dialysis in Dallas, Texas, to enroll in private, commercial health insurance plans in 2015 and that made it possible for workers to compare scheduled to vs. emergency-only dialysis among undocumented immigrants with ESRD.

Scheduled, thrice-weekly hemodialysis is an active, evidence-based treatment for prolonged and improving quality of life and is the standard of care for end-stage renal disease (ESRD).

1.2However, there is no universal coverage for scheduled dialysis in the United States via Medicare and Medicaid, not all individuals with ESRD in the United States receive this care.3,4 In 40 of 50 US states, uninsured individuals with ESRD who are ineligible for federal assistance, namely undocumented immigrants, receive emergency-only dialysis that is, dialysis that is intermittent and

Given in the emergency department (ED) only when imminently life-threatening indications are present as a result of withholding needed scheduled dialysis (severe metabolic acidosis; hyperkalemia with impending fatal arrhythmia; uremia with altered sensorium; or severe volume overload withhypoxia). 4.5 Individuals receive enough dialysis such that they are no longer on the precipice of death, as mandated under the 1986 Emergency Medical Treatment and Labor Act, and are instructed to return to the ED when symptoms indicating the need for dialysis again arise.

This observational study included 181 undocumented immigrants, 105 of whom received insurance coverage and enrolled in scheduled dialysis and 76 of whom remained uninsured.

Scheduled dialysis

Regularly scheduled dialysis (the standard of care for ESRD) compared with emergency-only dialysis (administered when a patient becomes life-threateningly ill) was associated with reductions in mortality, health care utilization and costs among patients with ESRD. The authors call for scheduled dialysis to be the standard of care for any patient with ESRD in the United States.?

Research used enrollment in health insurance and scheduled dialysis to estimate the influence of scheduled dialysis on 1-year mortality, utilization, and health care costs, using a propensity score–adjusted, intention-to-treat approach, including time-to-event analyses for mortality, difference-in-differences (DiD) negative binomial regression analyses for utilization, and DiD gamma generalized linear regression for health care costs.

Of 181 eligible adults with ESRD, 105 (65 men, 40 women; mean age, 45 years) received scheduled dialysis and 76 (38 men, 38 women; mean age, 52 years) received emergency-only dialysis.

Compared with emergency-only dialysis, scheduled dialysis was significantly associated with reduced mortality (3% vs 17%, P = .001; absolute risk reduction, 14%; number needed to treat, 7; adjusted hazard ratio, 4.6; 95% CI, 1.2-18.2; P = .03), adjusted emergency department visits (−5.2 vs +1.1 visits/mo; DiD, −6.2; P < .001), adjusted hospitalizations (−2.1 vs −0.5 hospitalizations/6 months; DiD, −1.6; P < .001).

Adjusted hospital days (-9.2 vs +0.8 days / 6 months; DiD, -9.9; P = .007), and adjusted costs (- $ 4316 vs + $ 1452 per person per month; DiD, – $ 5768; P <.001). In this study, dialysis was significantly associated with reduced 1-year mortality, health care utilization, and costs compared with emergency-only dialysis. Scheduled dialysis should be the universal standard of care for all individuals with ESRD in the United States.