Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease
Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease
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DOI：
10.1001/jama.2018.16504
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发表时间：
2018-12-04
影响因子：
120.7
通讯作者：
Trivedi, Amal N.
中科院分区：
文献类型：
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作者：
Swaminathan, Shailender;Sommers, Benjamin D.;Trivedi, Amal N.
重要性平价医疗法案医疗补助的扩大可能与死亡率的降低有关，但迄今为止的证据有限。终末期肾病(ESRD)患者是一个高危人群，尤其可能受到医疗补助扩大的影响。目的研究在非老年终末期肾病(ESRD)患者中，医疗补助扩大与1年死亡率的关系。设计、设置和参与者对2011年1月至2017年3月非老年患者在医疗补助扩大和非扩大状态下开始透析的设计、设置和参与者进行差异分析。结果共纳入142 724名处于扩张状态的患者(平均年龄50.2岁，女性占40.2%)和93 522名处于非扩张状态的患者(平均年龄49.7岁，占女性的42.4%)。在医疗补助扩展州，开始透析后的一年死亡率从扩张前的6.9%下降到扩张后的6.1%(变化，-0.8个百分点；95%可信区间，-1.1至-0.5)。在非扩张状态下，扩张前的死亡率为7.0%，扩张后的死亡率为6.8%(变化后为-0.2个百分点；95%可信区间为-0.5至0.2)，调整后扩张状态下的死亡率绝对值下降为-0.6个百分点(95%可信区间为-1.0至-0.2)。黑人患者(-1.4个百分点；95%CI，-2.2，-0.7；互动时P=0.04)和19至44岁患者(-1.1个百分点；95%CI，-2.1至-0.3；互动时P=0.01)死亡率下降幅度最大。扩大与透析开始时医疗补助覆盖率增加10.5个百分点(95%CI，7.7-13.2)，未投保减少-4.2个百分点(95%CI，-6.0-2.3)，动静脉瘘或移植物存在增加2.3个百分点(95%CI，0.6-4.1)相关。透析前肾病护理的变化不显著。结论在终末期肾病患者中，生活在根据《平价医疗法案》扩大医疗补助的状态下开始透析的患者与较低的1年死亡率相关。如果这种关联是因果关系，则需要进一步研究，以了解哪些因素可能对这一发现起到了作用。
IMPORTANCE The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion.OBJECTIVE To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis.DESIGN, SETTING, AND PARTICIPANTS Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017.EXPOSURE Living in a Medicaid expansion state.MAIN OUTCOMES AND MEASURES The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis.RESULTS A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant.CONCLUSIONS AND RELEVANCE Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.