1/14
Meet Hilda. I was one of her doctors. When she died, she left 2 sons behind. My grief about her situation brought anger and then determination.
A #tweetorial on outcomes, advocacy, and policy in dialysis access for undocumented immigrants.
#medtwitter #nephtwitter #NSMC
Meet Hilda. I was one of her doctors. When she died, she left 2 sons behind. My grief about her situation brought anger and then determination.
A #tweetorial on outcomes, advocacy, and policy in dialysis access for undocumented immigrants.
#medtwitter #nephtwitter #NSMC
2/14
Hilda suffered along with the other 80 undocumented immigrants with kidney failure, who in Colorado could only receive dialysis every 6 to 7 days when at the brink of death (=’emergency dialysis’).
journalofhospitalmedicine.com/jhospmed/artic…
Illustration @NathanAGray
Hilda suffered along with the other 80 undocumented immigrants with kidney failure, who in Colorado could only receive dialysis every 6 to 7 days when at the brink of death (=’emergency dialysis’).
journalofhospitalmedicine.com/jhospmed/artic…
Illustration @NathanAGray
3/14
An estimated 6000-8000 undocumented immigrants with kidney failure have limited access to care due to exclusion from Medicare, provisions of ACA & some Medicaid programs.
This U.S. map shows where dialysis is covered by Medicaid (green).
cjasn.asnjournals.org/content/14/8/1…
An estimated 6000-8000 undocumented immigrants with kidney failure have limited access to care due to exclusion from Medicare, provisions of ACA & some Medicaid programs.
This U.S. map shows where dialysis is covered by Medicaid (green).
cjasn.asnjournals.org/content/14/8/1…
4/14
What is the provision of dialysis for undocumented immigrants with kidney failure like in your state?
What is the provision of dialysis for undocumented immigrants with kidney failure like in your state?
5/14
When Hilda died, there was a lack of research on access to dialysis for undocumented immigrants.
Yet, there were many perspective narratives by clinicians who wanted to expand access.
@jeevsmd @katierizzolo @tessa_novick
ajkd.org/article/S0272-…
When Hilda died, there was a lack of research on access to dialysis for undocumented immigrants.
Yet, there were many perspective narratives by clinicians who wanted to expand access.
@jeevsmd @katierizzolo @tessa_novick
ajkd.org/article/S0272-…
6/14
We began research...
Compared to undocumented immigrants that received scheduled 3x/wk dialysis, those receiving emergency dialysis have a:
Mortality that is 5-fold worse at 1 yr: ja.ma/2CBsAFf
Mortality that is 14-fold worse at 5 yrs:
ja.ma/2Q4RwYI
We began research...
Compared to undocumented immigrants that received scheduled 3x/wk dialysis, those receiving emergency dialysis have a:
Mortality that is 5-fold worse at 1 yr: ja.ma/2CBsAFf
Mortality that is 14-fold worse at 5 yrs:
ja.ma/2Q4RwYI
7/14
Our qualitative study of patients found physical & psychosocial distress due to:
- symptom accumulation
- being turned away from treatment (despite being ill) due to triage by lab values
- the perceived imminence of death
- no access to transplant
ja.ma/2E2ogjg
Our qualitative study of patients found physical & psychosocial distress due to:
- symptom accumulation
- being turned away from treatment (despite being ill) due to triage by lab values
- the perceived imminence of death
- no access to transplant
ja.ma/2E2ogjg
8/14
We found that emergency dialysis is hard on clinicians too:
Led to burnout due to:
- witnessing needless suffering & high mortality
- moral distress because care is reflective of immigration status
acpjournals.org/doi/10.7326/M1…
We found that emergency dialysis is hard on clinicians too:
Led to burnout due to:
- witnessing needless suffering & high mortality
- moral distress because care is reflective of immigration status
acpjournals.org/doi/10.7326/M1…
9/14
And emergency dialysis is also difficult for family because they experienced
- death anxiety
- physical and emotional exhaustion
Also, children acting as caregivers dropped out or missed school and faced psychosocial distress.
link.springer.com/article/10.100…
And emergency dialysis is also difficult for family because they experienced
- death anxiety
- physical and emotional exhaustion
Also, children acting as caregivers dropped out or missed school and faced psychosocial distress.
link.springer.com/article/10.100…
10/14
Comparing utilization/costs between undocumented immigrants that receive emergency dialysis vs 3x/week scheduled dialysis:
- 5 fewer ED visits per month
- 1.6 fewer hospital days per 6 month
- savings of $6000 per person per month
ja.ma/3aA9gVG
@OanhKieuNguyen
Comparing utilization/costs between undocumented immigrants that receive emergency dialysis vs 3x/week scheduled dialysis:
- 5 fewer ED visits per month
- 1.6 fewer hospital days per 6 month
- savings of $6000 per person per month
ja.ma/3aA9gVG
@OanhKieuNguyen
11/14
What’s the solution?
EMTALA- A federal law allowing Emergency Medicaid that specifies that hospitals provide emergency services to anyone w/an emergency medical condition.
As of now, CMS provides no subregulatory guidance on the definition of emergency medical condition
What’s the solution?
EMTALA- A federal law allowing Emergency Medicaid that specifies that hospitals provide emergency services to anyone w/an emergency medical condition.
As of now, CMS provides no subregulatory guidance on the definition of emergency medical condition
12/14
States can define what constitutes an emergency medical condition.
On Feb 1, 2019, guided by our research, Colorado Medicaid opted to include kidney failure in the definition of an ‘emergency medical condition’ expanding access to scheduled dialysis to the uninsured.
States can define what constitutes an emergency medical condition.
On Feb 1, 2019, guided by our research, Colorado Medicaid opted to include kidney failure in the definition of an ‘emergency medical condition’ expanding access to scheduled dialysis to the uninsured.
13/14
Step by step guidance to change access state by state:
-Gather a coalition who can develop case for change & influence decision-makers
-Engage media
-Gather the data
-Provide policy analysis
-Monitor outcomes
cnn.com/2018/08/02/hea…
cjasn.asnjournals.org/content/early/…
Step by step guidance to change access state by state:
-Gather a coalition who can develop case for change & influence decision-makers
-Engage media
-Gather the data
-Provide policy analysis
-Monitor outcomes
cnn.com/2018/08/02/hea…
cjasn.asnjournals.org/content/early/…
14/14
We are only as healthy as the most vulnerable among us.
Today, despite the COVID-19 pandemic, undocumented immigrants continue to receive emergency dialysis in many states. This increases unnecessary exposure + use valuable ED resources.
ajkd.org/article/S0272-…
We are only as healthy as the most vulnerable among us.
Today, despite the COVID-19 pandemic, undocumented immigrants continue to receive emergency dialysis in many states. This increases unnecessary exposure + use valuable ED resources.
ajkd.org/article/S0272-…
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