Kidney Week

Abstract: TH-OR01

Nonoptimal ESKD Starts before and after Medicaid Expansion

Session Information

• Achieving More Equitable Kidney Care
  October 24, 2024 | Location: Room 7, Convention Center
  Abstract Time: 04:30 PM - 04:40 PM

Category: Diversity and Equity in Kidney Health

• 900 Diversity and Equity in Kidney Health

Authors

• Roetker, Nicholas S., Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States

Nicholas S. Roetker, MS, PhD

• Liu, Jiannong, Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States

Jiannong Liu, PhD

• Guo, Haifeng, Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States

Haifeng Guo, MS

• Gilbertson, David T., Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States

David T. Gilbertson, PhD

• Wetmore, James B., Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States

James B. Wetmore, MD, MS

• Johansen, Kirsten L., Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, United States

Kirsten L. Johansen, MD, FASN

Background

Initiating in-center hemodialysis with a central venous catheter represents a nonoptimal start of end-stage kidney disease (ESKD). We studied whether nonoptimal start rates were higher in residents of 11 states that did not expand Medicaid access in 2014 relative to residents of 27 states that did.

Methods

We included yearly data from 2006-2019 for persons aged 18-64 years. We identified age, sex, and race/ethnicity state-level population estimates using US Census Bureau data and counts of nonoptimal ESKD starts from the US Renal Data System. We compared incidence rates between expansion and non-expansion states in the pre- and post-expansion periods using age, sex, and race/ethnicity adjusted Poisson regression.

Results

Before Medicaid expansion, the yearly rate of nonoptimal ESKD starts was 216.8 cases per million persons (PMP) in non-expansion states and 199.3 PMP in expansion states, with rates decreasing in both groups across this period (Figure). After Medicaid expansion, nonoptimal start rates were relatively stable in the expansion states (191.2 cases PMP) but increased in the non-expansion states (216.9 cases PMP). Thus, compared with the expansion states, the average yearly incidence was 17.4 (95% CI 15.8–19.1) PMP higher in non-expansion states in the pre-expansion period and 25.7 (95% CI 23.9–27.5) PMP higher in the post-expansion period (post vs pre difference in difference: 8.2; 95% CI 5.8–10.7 PMP). Notably, the difference in difference estimates were highest among the age 45-64 years (17.3; 95% CI 12.0–22.7 PMP) and non-Hispanic White (16.2; 95% CI 13.6–18.8 PMP) subgroups.

Conclusion

In the 6 years after enactment of the Affordable Care Act, rates of nonoptimal ESKD start were stable in states that expanded access to Medicaid but increased in states that did not. Further studies should examine whether increases in nonoptimal starts in non-expansion states may be attributable to less access to healthcare among uninsured persons with kidney disease.

Funding

• NIDDK Support