Thousands of uninsured kidney disease patients strain Texas emergency departments

More than 10,000 uninsured patients sought care at Texas emergency departments for lifesaving kidney dialysis in 2017, incurring more than $21.8 million in hospital costs, according to researchers from The University of Texas Health Science Center at Houston (UTHealth).

The study, which highlights a common problem in emergency departments across the country, was published today in JAMA Network Open.

The kidneys filter blood by removing waste and excess fluid. Patients with kidneys that no longer function require dialysis, where they are hooked up to a machine that purifies their blood. Each dialysis treatment takes an average of four hours three times a week. For many uninsured patients, waiting until the need becomes life-threatening is the only option because regular treatment is not feasible.

"This is a real problem facing these patients," said Julianna West, a second-year student at McGovern Medical School at UTHealth and lead author of the paper. "They have gone weeks without dialysis, and then they present in life-threatening crisis to the emergency department. This requires many hospital personnel and resources to treat their dire condition, and takes time and resources away from other patients that also need emergent treatment."

"This is a very sick population—the population with the highest morbidity rate in any emergency department," said John Foringer, MD, professor of internal medicine in the Division of Renal Diseases and Hypertension at McGovern Medical School and chief of medicine at Harris Health Lyndon B. Johnson Hospital. "This study is important because there is little data available that really captures the magnitude of the issue. Without data, it is difficult to improve resource utilization to manage these patients."

Emergent dialysis also carries a substantial price tag. Scheduled dialysis in an outpatient clinic costs about $250, while intermittent treatment in the emergency department costs eight times more, about $2,000.

"A system that treats the patient only when gravely ill provides less quality of care and is less cost-effective than investing in a program that schedules the unfunded kidney disease patients with a dialysis slot," said David Robinson, MD, MS, professor of emergency medicine with McGovern Medical School, former chief of emergency medicine of Harris Health LBJ in 2017, and a co-author of the study. "The emergency department, which often serves as the safety net for the indigent, was being used as an acute safety net for a serious chronic disease."

Harris Health System has implemented innovative solutions in the past decade to help connect uninsured patients with scheduled dialysis outside of the emergency department, Foringer said. For example, Harris Health's Riverside Dialysis Center, a chronic dialysis unit, serves nearly 180 patients who would otherwise be receiving intermittent care through hospital emergency services, he said.

Foringer also recently helped Riverside begin a new service offering patients peritoneal dialysis, which involves a surgery to place a catheter in the belly to run sterile cleansing fluid in and out of the abdominal cavity. After the initial surgery, the treatment can be done from home.

"Through the services offered at Riverside and other initiatives we've helped Harris Health implement over the years, now emergent dialysis treatments are half of what they used to be at Harris Health LBJ, from 300 in 2018 to now about 150 a month. We're starting to see the fruits of those efforts," said Foringer, who is a co-author of the study.

Researchers used Texas Emergency Department Data to evaluate adult visits in 2017 with a one-day stay or less.

"The data does not even capture those who were immediately admitted to the intensive care unit, or those that were turned away," said Henry Wang, MD, emergency medicine professor at McGovern Medical School and senior author of the paper. "Because of those limitations, this data really just captures the tip of the iceberg. This study highlights the balancing act emergency room physicians must perform with hospital resources, due to issues with health care that go far beyond the emergency department."

For West, the issue was personal.

"Before medical school, I worked as an EMT and cared for many patients in the final stages of kidney disease," West said. "I witnessed the pain and suffering of patients who went without scheduled dialysis treatment, and I also saw the enormous improvement in quality of life and joy when they did receive their scheduled dialysis. My experience inspired me to advocate for this patient population and begin research to gather more information about this public health problem so that proper solutions could be implemented."