Health Insurance in the First 3 Months of Hemodialysis and Early Vascular Access

Eugene Lin, Matthew Mell, Wolfgang C. Winkelmayer, Kevin F. Erickson

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


BACKGROUND AND OBJECTIVES: Patients without Medicare who develop ESKD in the United States become Medicare eligible by their fourth dialysis month. Patients without insurance may experience delays in obtaining arteriovenous fistulas or grafts before obtaining Medicare coverage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective cohort study, we used a national registry to compare uninsured patients starting in-center hemodialysis with a central venous catheter between 2010 and 2013 with similar patients with Medicare or Medicaid. We evaluated whether insurance status at dialysis start influenced the likelihoods of switching to dialysis through an arteriovenous fistula or graft and hospitalizations involving a vascular access infection. We used multivariable logistic and Cox regression models and transformed odds ratios to relative risks using marginal effects. RESULTS: Patients with Medicare or Medicaid were more likely to switch to an arteriovenous fistula or graft by their fourth dialysis month versus uninsured patients (Medicare hazard ratio, 1.63; 95% confidence interval, 1.14 to 2.43; Medicaid hazard ratio, 1.23; 95% confidence interval, 1.12 to 1.38). There were no differences in rates of switching to arteriovenous fistulas or grafts after all patients obtained Medicare in their fourth dialysis month (Medicare hazard ratio, 1.17; 95% confidence interval, 0.97 to 1.42; Medicaid hazard ratio, 1.01; 95% confidence interval, 0.96 to 1.06). Patients with Medicare at dialysis start had fewer hospitalizations involving vascular access infection in dialysis months 4-12 (hazard ratio, 0.60; 95% confidence interval, 0.37 to 0.97). CONCLUSIONS: Insurance-related disparities in the use of arteriovenous fistulas and grafts persist through the fourth month of dialysis, may not fully correct after all patients obtain Medicare coverage, and may lead to more frequent vascular access infections.

Original languageEnglish (US)
Pages (from-to)1866-1875
Number of pages10
JournalClinical journal of the American Society of Nephrology : CJASN
Issue number12
StatePublished - Dec 7 2018


  • arteriovenous fistula
  • Central Venous Catheters
  • clinical epidemiology
  • Economic Impact
  • hemodialysis access
  • hospitalization
  • Insurance Coverage
  • Insurance, Health
  • Kidney Failure, Chronic
  • Medicaid
  • Medically Uninsured
  • Medicare
  • Odds Ratio
  • Registries
  • renal dialysis
  • Retrospective Studies
  • Risk
  • United States Renal Data System

ASJC Scopus subject areas

  • Epidemiology
  • Critical Care and Intensive Care Medicine
  • Nephrology
  • Transplantation


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