Care of undocumented-uninsured immigrants in a large urban dialysis unit

Abstract

BackgroundMedical, ethical and financial dilemmas may arise in treating undocumented-uninsured patients with end-stage renal disease (ESRD). Hereby we describe the 10-year experience of treating undocumented-uninsured ESRD patients in a large public dialysis-unit.MethodsWe evaluated the medical files of all the chronic dialysis patients treated at the Tel-Aviv Medical Center between the years 2000–2010. Data for all immigrant patients without documentation and medical insurance were obtained. Clinical data were compared with an age-matched cohort of 77 insured dialysis patients.ResultsFifteen undocumented-uninsured patients were treated with chronic scheduled dialysis therapy for a mean length of 2.3 years and a total of 4953 hemodialysis sessions, despite lack of reimbursement. All undocumented-uninsured patients presented initially with symptoms attributed to uremia and with stage 5 chronic kidney disease (CKD). In comparison, in the age-matched cohort, only 6 patients (8%) were initially evaluated by a nephrologist at stage 5 CKD. Levels of hemoglobin (8.5 ± 1.7 versus 10.8 ± 1.6 g/dL; p < 0.0001) and albumin (33.8 ± 4.8 versus 37.7 ± 3.9 g/L; p < 0.001) were lower in the undocumented-uninsured dialysis patients compared with the age-matched insured patients at initiation of hemodialysis therapy. These significant changes were persistent throughout the treatment period. Hemodialysis was performed in all the undocumented-uninsured patients via tunneled cuffed catheters (TCC) without higher rates of TCC-associated infections. The rate of skipped hemodialysis sessions was similar in the undocumented-uninsured and age-matched insured cohorts.ConclusionsUndocumented-uninsured dialysis patients presented initially in the advanced stages of CKD with lower levels of hemoglobin and worse nutritional status in comparison with age-matched insured patients. The type of vascular access for hemodialysis was less than optimal with regards to current guidelines. There is a need for the national and international nephrology communities to establish a policy concerning the treatment of undocumented-uninsured patients with CKD.

Eritrean Refugees’ Utilization of Antenatal Services in Israel

“…Instead, the majority of the women in Eilat and Tel Aviv reported use of facilities that operate outside the regular system of Israeli antenatal services, such as the Terem clinic and the hospital, which are not meant to be the main facility for uptake of antenatal services. Our qualitative data do not provide direct answers to these surprising findings, nor do other studies on Eritrean refugees' utilization of health services reflect on their facility choices for service uptake (Chernin et al, 2012;Michaan et al, 2014;Fleischman et al, 2015;Gebreyesus et al, 2017). Nevertheless, the current research results do suggest that the Israeli system of antenatal care is not completely functional for Eritrean women, so that the women pursue services in facilities outside the regular Israeli antenatal care system.…”

“…Chernin et al. () reported similar results for undocumented immigrants’ utilization of health services for end‐stage renal disease, suggesting that frequent utilization of a given service is particularly challenging for Eritrean refugees in Israel. While more experience did not affect the array of services used, frequency rates in the current study were higher for women with more children born in Israel.…”

Should we perform kidney transplants on foreign nationals?

“…The study authors concluded that their data contradict the widely held opinion that people are moving to the USA to receive dialysis treatment 25. An Israeli study showed similar results 26. There are no Canadian data on this issue, and the situation might be different from that in the USA, of Canada's universal health insurance; for example, in France, where there is also universal health insurance, the proportion of FN patients waitlisted for an organ transplant increased between 1996 and 2008 13 16…”

“…Once in the new country, they face multiple barriers in accessing healthcare services (eg, language, lack of knowledge about how the healthcare system works, and about their rights or the resources available to them), may be isolated and without social support, and be stressed about their immigration status 34. This situation can lead FNs to consult late, not receive optimal medical management and thus be in worse health 26. Nonetheless, this vulnerability may be considered insufficient grounds to justify particular attention or care from a host country.…”

Medical Care for Undocumented Immigrants

“…[17][18][19] Another argument, from a cost perspective, is that many UIs will benefit from preventive care and early treatment of chronic diseases before they advance to lifethreatening and costly complications. 20,21 Proponents of this strategy advocate for improving health literacy and vaccination rates, and offering health screenings to the UI population to try to prevent long-term adverse health outcomes and control cost. Moreover, UIs may harbor infections such as tuberculosis (TB), which, when undetected, can easily be transmitted to the general public, thus posing a public health risk.…”