Association of Medicaid Expansion with Tunneled Dialysis Catheter Use at the Time of First Arteriovenous Access Creation
Scott R. Levin, M.D., M.Sc.1, Alik Farber, M.D., M.B.A., F.A.C.S.1, Mohammad H. Eslami, M.D., M.P.H., F.A.C.S.2, Tze-Woei Tan, M.D., F.A.C.S.3, Nicholas H. Osborne, M.D., M.S.4, Jean M. Francis, M.D.5, Sandeep Ghai, M.D.5, Jeffrey J. Siracuse, M.D., M.B.A., F.A.C.S.1
1Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA 2Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 3Division of Vascular Surgery, University of Arizona, Tucson, AZ 4Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI 5Section of Nephrology, Boston Medical Center, Boston University School of Medicine, Boston, MA
Background: The Affordable Care Act expanded Medicaid eligibility among low-income adults. Many patients initiating hemodialysis are uninsured before qualifying for Medicare. Inadequate access to pre-dialysis care could delay their arteriovenous (AV) access creation and increase tunneled dialysis catheter (TDC) use. We evaluated whether Medicaid expansion was associated with decreased TDC use for hemodialysis initiation.
Methods: We queried the Vascular Quality Initiative state-level database for non-Medicare patients undergoing initial AV access creations. We evaluated associations of insurance coverage, concurrent TDC use, and postoperative survival with state Medicaid expansion status.
Results: Data were available for patients in 31 states from 2011-2018: 19 states expanded Medicaid. Among 8,462 patients in the post-expansion period from 2015-2018, 58% were in Medicaid expansion states. Patients in Medicaid expansion states less often had concurrent TDCs (40% vs 48%, P<.001). After multivariable analysis, state Medicaid expansion status was independently associated with fewer TDCs (OR 0.7, 95% CI 0.6-0.8, P<.001). Three-year survival was similar between patients in Medicaid expansion and nonexpansion states (84.7% vs 85.2%, P=.053). Multivariable cox-regression confirmed the finding (HR 0.95, 95% CI 0.82-1.1, P=.482). Difference-in-differences analysis demonstrated a 9.2-percentage point increase in Medicaid coverage associated with Medicaid expansion (95% CI 2.7-15.8, P=.009). Hispanic patients exhibited a 30.1-percentage point increase in any insurance coverage (95% CI .3-59.9, P=.048).
Conclusion: Patients in Medicaid expansion states were less likely to have TDCs during initial access creation, suggesting earlier pre-dialysis care. Hispanic patients benefited from increased insurance coverage. Medicaid expansion may improve quality metrics and cost-savings for hemodialysis patients.
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