Uninsured patients who initiate hemodialysis prior to age 65 years ultimately qualify for Medicare coverage, but there is a 3-month lag before this occurs. Any medical care provided during the first 3 months of dialysis is not reimbursed. Clearly, this policy creates delays in the placement of a vascular access, as surgeons are reluctant to perform surgery for free.
Lin and colleagues quantified the consequences of lack of health insurance in the first 3 months of hemodialysis on the likelihood of achieving a permanent vascular access. They compared two patient cohorts without pre-ESRD nephrology follow-up who initiated dialysis with a central vein catheter (CVC) between 2010 and 2013: patients aged 65 to 69 years with prior Medicare coverage and uninsured patients aged 60 to 64 years.
The likelihood of using an arteriovenous fistula (AVF) or arteriovenous graft (AVG) by the fourth dialysis month was lower in the uninsured patient group (11% vs 16%). This difference was associated with a higher likelihood of hospitalization due to vascular access infection in the uninsured patient cohort. Among those patients who were still catheter-dependent at the end of their fourth month on dialysis (when the uninsured patients qualified for Medicare), there was no difference in the time to switching to AVF or AVG use over the ensuing 8 months.
These findings suggest that a change in Medicare policy to establish coverage immediately upon dialysis initiation would increase early AVF use, but the benefit would be modest. There are many other obstacles to achieving timely AVF use. A recent DOPPS publication reported a median time of 82 days from AVF creation to first successful use. In other words, only about half would be used within 3 months. A substantial proportion of new AVFs fail to mature, and many require surgical or percutaneous interventions to promote their maturation. Even among insured patients with 1-year pre-ESRD nephrology follow-up, only 60% undergo access surgery before dialysis initiation. Moreover, among patients with pre-ESRD AVF surgery, about 50% still initiate dialysis with a CVC.
Clearly, the fragmented nature of medical care is a huge contributor to poor vascular access outcomes.
Michael Allon, MD
Professor of Medicine
Division of Nephrology
University of Alabama at Birmingham
Editorial Advisory Board Member
Nephrology News & Issues
Disclosures: Allon has no relevant financial disclosures.