Care of undocumented individuals with ESRD: a national survey of US nephrologists

Laura Hurley, Allison Kempe, Lori A Crane, Arthur Davidson, Katherine Pratte, Stuart Linas, L Miriam Dickinson, Tomas Berl
American Journal of Kidney Diseases 2009, 53 (6): 940-9

BACKGROUND: Although Medicare covers most dialysis therapy for US citizens with end-stage renal disease (ESRD), no national standards for dialysis provision exist for undocumented (ie, immigrant) patients with ESRD.

STUDY DESIGN: Cross-sectional survey.

SETTING & PARTICIPANTS: Mail and internet survey from October 2006 to February 2007 of American Society of Nephrology member nephrologists.

PREDICTORS: Region of the country, practicing in a state with a high undocumented population, inpatient and outpatient practice setting, and practice location.

OUTCOMES: Characteristics of nephrologists who report caring for undocumented patients with ESRD and those who perceive that such patients have access to maintenance dialysis therapy.

RESULTS: Response rate was 57% (990 of 1,723). Of nephrologists surveyed, 65%, representing 44 states, reported providing care to undocumented patients with ESRD and 61% reported increasing prevalence. Being from a state with a high undocumented population (OR, 1.67; 95% CI, 1.21 to 2.30) was associated with undocumented ESRD patient care; being from the Northeastern United States (OR, 0.55; 95% CI, 0.34 to 0.88) or a small town/rural area (OR, 0.27; 95% CI, 0.18 to 0.40) were negatively associated. Of the respondents, 91% reported that undocumented patients had access to emergent dialysis, but only 51% reported access to maintenance dialysis therapy. The characteristic associated with reporting access to maintenance dialysis was practicing in a state with a high undocumented population (OR, 1.91; 95% CI, 1.37 to 2.66), whereas practicing in the Southern United States was negatively associated (OR, 0.37; 95% CI, 0.24 to 0.57). Emergent-only dialysis for undocumented patients was reported by 28%. Of respondents knowledgeable about reimbursement, most reported inadequate compensation and 35% reported that outpatient dialysis units provide uncompensated dialysis care to undocumented patients with ESRD.

LIMITATIONS: Selection and information biases inherent to survey methods.

CONCLUSIONS: Dialysis for undocumented patients with ESRD is an increasing problem involving the majority of US nephrologists. Inadequately compensated or uncompensated care may limit the availability of long-term maintenance dialysis therapy for undocumented patients with ESRD. Regional variations argue for more rational and uniform national policy regarding this issue.

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