Changes in Migration and Mortality Among Patients With Kidney Failure in Puerto Rico After Hurricane Maria

Abstract

ImportanceOn September 20, 2017, one of the most destructive hurricanes in US history made landfall in Puerto Rico. Anecdotal reports suggest that many persons with kidney failure left Puerto Rico after Hurricane Maria; however, empirical estimates of migration and health outcomes for this population are scarce.ObjectiveTo assess the changes in migration and mortality among patients with kidney failure in need of dialysis treatment in Puerto Rico after Hurricane Maria.Design, Setting, and ParticipantsThis cross-sectional study used an interrupted time-series design of 6-month mortality rates and migration of 11 652 patients who received hemodialysis or peritoneal dialysis care in Puerto Rico before Hurricane Maria (before October 1, 2017) and/or during and after Hurricane Maria (on/after October 1, 2017). Data analyses were performed from February 12, 2019, to June 16, 2022..Main Outcomes and MeasuresNumber of unique persons dialyzed in Puerto Rico per quarter; receipt of dialysis treatment outside Puerto Rico per quarter; and 6-month mortality rate per person-quarter for all persons undergoing dialysis.ExposuresHurricane Maria.ResultsThe entire study sample comprised 11 652 unique persons (mean [SD] age, 59 [14.7] years; 7157 [61.6%] men and 4465 [38.4%] women; 10 675 [91.9%] Hispanic individuals). There were 9022 patients with kidney failure and dialysis treatment before and 5397 patients after Hurricane Maria. Before the hurricane, the mean quarterly number of unique persons dialyzed in Puerto Rico was 2834 per quarter (95% CI, 2771-2897); afterwards it dropped to 261 (95% CI, −348 to −175; relative change, 9.2%). The percentage of persons who had 1 or more dialysis sessions outside of Puerto Rico in the next quarter following a previous dialysis in Puerto Rico was 7.1% before Hurricane Maria (95% CI, 4.8 to 9.3). There was a significant increase of 5.8 percentage points immediately after the hurricane (95% CI, 2.7 to 9.0). The 6-month mortality rate per person-quarter was 0.08 (95% CI, 0.08 to 0.09), and there was a nonsignificant increase in level of mortality rates and a nonsignificant decreasing trend in mortality rates.Conclusions and RelevanceThe findings of this cross-sectional study suggest there was a significant increase in the number of people receiving dialysis outside of Puerto Rico after Hurricane Maria. However, no significant differences in mortality rates before and after the hurricane were found, which may reflect disaster emergency preparedness among dialysis facilities and the population with kidney failure, as well as efforts from other stakeholders.

What's the Weather Like Today? Forecasting a Chance of Shower, Snow, and… Missing Dialysis

“…The authors credited adherence to disaster preparedness guidelines and early government responses and care delivery as potential reasons for this finding. 7 Although Remigio and colleagues attribute the lack of a persistent lagged risk of missing dialysis in the setting of hurricanes and tropical storms in this study to early in-center hemodialysis ahead of anticipated weather events, the frequency of early dialysis was not reported, and whether only certain facilities or certain patients received early dialysis ( e.g. , those not planning to evacuate) is unclear.…”

“…The authors credited adherence to disaster preparedness guidelines and early government responses and care delivery as potential reasons for this finding. 7 Although Remigio and colleagues attribute the lack of a persistent lagged risk of missing dialysis in the setting of hurricanes and tropical storms in this study to early in-center hemodialysis ahead of anticipated weather events, the frequency of early dialysis was not reported, and whether only certain facilities or certain patients received early dialysis (e.g., those not planning to evacuate) is unclear. Temporal trends in the association between weather and missed hemodialysis appointments were also not described, although improvements in emergency preparedness over the past two decades could potentially have attenuated the relation between inclement weather and missed dialysis treatments over time.…”

Health Effects of Cyclones: A Systematic Review and Meta-Analysis of Epidemiological Studies

“…Eight studies assessed the excess mortality in Puerto Rico after Hurricane Maria. 8 , 49 – 55 We included only the paper by Cruz-Cano and Mead 8 because it included the longest study period and largest amount of data and reported cause-specific excess mortality instead of focusing only on all-cause excess mortality or subpopulation (e.g., Hispanic origin, patients with kidney failure) compared with the other studies. Finally, 71 eligible papers were included in the review, and 32 estimates from 18 of the included studies underwent a further meta-analysis.…”

Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure

“…Notably, natural disasters such as hurricanes have not demonstrated a difference in mortality in Puerto Rico for people receiving dialysis. [48][49][50][51] Indeed, there was no difference in the risk of death between Puerto Rican versus US-born Hispanic patients living in Puerto Rico. However, those originating from Puerto Rico living in the US 50 states still had a higher adjusted risk of death, suggesting that more research needs to be performed to understand the mechanism behind this moderately increased risk.…”