Care of Undocumented Individuals With ESRD: A National Survey of US Nephrologists

Background Although Medicare covers most dialysis therapy for US citizens with end-stage renal disease (ESRD), no national standards for dialysis provision exist for undocumented (ie, immigrant) patients with ESRD. Study Design Cross-sectional survey. Setting & Participants Mail and internet survey from October 2006 to February 2007 of American Society of Nephrology member nephrologists. Predictors Region of the country, practicing in a state with a high undocumented population, inpatient and outpatient practice setting, and practice location. Outcomes Characteristics of nephrologists who report caring for undocumented patients with ESRD and those who perceive that such patients have access to maintenance dialysis therapy. Results Response rate was 57% (990 of 1,723). Of nephrologists surveyed, 65%, representing 44 states, reported providing care to undocumented patients with ESRD and 61% reported increasing prevalence. Being from a state with a high undocumented population (OR, 1.67; 95% CI, 1.21 to 2.30) was associated with undocumented ESRD patient care; being from the Northeastern United States (OR, 0.55; 95% CI, 0.34 to 0.88) or a small town/rural area (OR, 0.27; 95% CI, 0.18 to 0.40) were negatively associated. Of the respondents, 91% reported that undocumented patients had access to emergent dialysis, but only 51% reported access to maintenance dialysis therapy. The characteristic associated with reporting access to maintenance dialysis was practicing in a state with a high undocumented population (OR, 1.91; 95% CI, 1.37 to 2.66), whereas practicing in the Southern United States was negatively associated (OR, 0.37; 95% CI, 0.24 to 0.57). Emergent-only dialysis for undocumented patients was reported by 28%. Of respondents knowledgeable about reimbursement, most reported inadequate compensation and 35% reported that outpatient dialysis units provide uncompensated dialysis care to undocumented patients with ESRD. Limitations Selection and information biases inherent to survey methods. Conclusions Dialysis for undocumented patients with ESRD is an increasing problem involving the majority of US nephrologists. Inadequately compensated or uncompensated care may limit the availability of long-term maintenance dialysis therapy for undocumented patients with ESRD. Regional variations argue for more rational and uniform national policy regarding this issue.