Outcomes Of Hemodialysis Access Among Patients Experiencing Housing Instability
Eric Sung, BA, Scott Levin, MD, Rohith Kariveda, Alik Farber, MD, Elizabeth King, MD, Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.
ObjectiveEnd stage renal disease (ESRD) has traditionally disproportionately affected patients with fewerresources. Our goal was to assess practice patterns and outcomes in patients with unstablehousing (homeless or have 3 or more address changes within 12 months) undergoing permanenthemodialysis access creation.MethodsA retrospective, single center review of patients with unstable housing undergoing hemodialysisaccess creation between 2015-2017 was conducted. Perioperative and long-term outcomes wereassessed.ResultsWe identified 144 patients (82% male) with a mean age of 57 years. There were 33% homelessand 81% had at least 3 addresses the year prior to operation. Primary insurance was Medicaid(60%), Medicare (39%), or commercial (1%) and 31% of cases were performed while inpatient.Access type included brachiocephalic (48%), brachiobasilic (19%), radiocephalic (11%),prosthetic (19%), or other (3%). Patients were discharged to a family or friends house (39%),home (19%), a long-term care facility (10%), or other (19%). Highest level of education includedprimary (23%), secondary (50%), post-secondary (5%), or other (22%). Few patients wereemployed (10%), but many reported having social support (88%). Ninety-day readmission rateswere seen in 50.7% of patients, with prior access (OR, 3.70; 95% CI, 1.02-12.5; P = 0.047),homelessness (OR, 2.91; 95% CI, 1.15-7.44; P = 0.025), and female sex (OR, 2.86; 95% CI,1.18-7.14, P = 0.021) independently associated.Kaplan-Meier analysis showed 1- and 4-year survival to be 94.4% and 80.6%, respectively.Multivariate analysis revealed previous stroke (HR, 7.15; 95% CI, 1.93-26.51; P = 0.003),history of alcohol abuse (HR, 4.55; 95% CI, 1.22-16.99; P = 0.024), and age (HR, 1.10; 95% CI,1.02-1.18; P = 0.017) were associated with four-year mortality. Three or more address changesand homelessness were not associated with increased reintervention or decreased survival.ConclusionPoor outcomes in patients with unstable housing are primarily driven by comorbidities.Outcomes for this high-risk population are similar to previously reported general populationdata.
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