Vocational activity and health insurance type among patients with end-stage renal disease: association with outcomes
It is widely thought that patients with end-stage renal disease who remain vocationally active and/or commercially insured following dialysis initiation have better clinical outcomes and higher quality of life than those who do not. However, scientifically robust data are lacking. Here, we examined whether vocational status (active, N = 1848; inactive, N = 10,001) and, separately, insurance status (commercial, N = 4858; Medicare/self-pay, N = 13,329; Medicaid, N = 3528) were associated with clinical outcomes and Kidney Disease Quality of Life (KDQOL) scores among a cohort of patients who initiated dialysis at a large US dialysis organization during 2015–2016. Outcomes were considered from the day after index (31 days after dialysis initiation for vocational status and 1 day after initiation for insurance status) until the earliest of death, discontinuation of dialysis, transplant, loss to follow-up, or end of study (30 September 2016). Comparisons were made using intention-to-treat principles and generalized linear models adjusted for imbalanced patient characteristics, including sociodemographic variables. Vocational inactivity (vs. vocational activity) was independently associated with higher rates of mortality and hospitalization, lower rates of transplant, and lower KDQoL scores in 4 of 5 domains. Similar trends were observed when comparing Medicare/self-pay or Medicaid insurance to commercial insurance. Vocational activity, and separately, commercial insurance, were independently associated with better clinical and quality of life outcomes compared to other insurance and vocational categories. These findings may inform patient and physician education, and guide advocacy efforts.
KeywordsEnd-stage renal disease Dialysis Health insurance Vocational activity Outcomes
We acknowledge the helpful contributions of all members of the Healthcare Analytics and Insights team at DaVita Clinical Research. We also acknowledge informative conversations with Daniel Galemba of DaVita, Inc. An abstract describing this work was accepted for presentation at the American Society for Nephrology Kidney Week, New Orleans, LA, November 2–5, 2017.
Compliance with ethical standards
Conflict of interest
This work was supported by DaVita, Inc. All of the authors are current or former employees of DaVita Clinical Research. SMB’s spouse is an employee of AstraZeneca.
Research involving human participants and/or animals
This retrospective study was conducted using deidentified patient data. As such, it was deemed exempt from institutional review board or ethics committee approval. No research involving animals was performed.
Because the study was conducted using deidentified patient data, informed consent was not required. We adhered to the Declaration of Helsinki.
- 6.Imanishi Y, Fukuma S, Karaboyas A, Robinson BM, Pisoni RL, Nomura T, Akiba T, Akizawa T, Kurokawa K, Saito A, Fukuhara S, Inaba M (2017) Associations of employment status educational levels with mortality hospitalization in the dialysis outcomes practice patterns study in Japan. PLoS One 12(3):e0170731CrossRefPubMedPubMedCentralGoogle Scholar
- 8.The United States Renal Data System 2016 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, 2016, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, BethesdaGoogle Scholar
- 14.National Center for Healthcare Statistics. Health Insurance and Access to Care. NCHS Fact Sheet 2017. https://www.cdc.gov/nchs/data/factsheets/factsheet_hiac.pdf. Accessed 19 July 2017