Abstract
RATIONALE & OBJECTIVE: Unemployment is common among patients receiving maintenance dialysis, and peritoneal dialysis (PD) may better facilitate employment and employer-sponsored health insurance compared with hemodialysis (HD). This study assessed the employment status of dialysis recipients and examined the association between dialysis modality and the likelihood of insurance transitions after dialysis initiation using employer-sponsored health insurance status as a proxy for patient or household employment. STUDY DESIGN: National retrospective cohort study. SETTING & PARTICIPANTS: Patients represented in the United States Renal Data System who initiated dialysis between January 1, 2013, and December 31, 2018, were followed for between 3 and 30 months. A total of 18,408 in-center HD (IHD) and PD recipients who were employed on a full-time basis at the time of dialysis initiation and had employer-sponsored health insurance for 3 months after dialysis were followed for loss of employer-sponsored health insurance. A total of 104,952 IHD and PD recipients who were unemployed at the time of dialysis initiation and had no employer-sponsored health insurance at 3 months after dialysis initiation were followed for initiation of employer-sponsored health insurance. EXPOSURE: Dialysis modality 3 months after dialysis initiation categorized as IHD with an HD fistula, IHD without a fistula, or PD. OUTCOMES: Employer-sponsored health insurance loss or gain. ANALYTICAL APPROACH: Cause-specific hazards modeling. RESULTS: Compared with patients receiving PD, patients receiving IHD without a fistula (HR, 1.26; 95% CI, 1.18-1.36) and with a fistula (HR, 1.14; 95% CI, 1.05-1.24) were more likely to lose employer-sponsored health insurance. Compared with patients receiving PD, patients receiving IHD without a fistula (HR, 0.55; 95% CI, 0.49-0.61) and with a fistula (HR, 0.59; 95% CI, 0.52-0.67) were less likely to gain employer-sponsored insurance. LIMITATIONS: Employer-sponsored health insurance may not be a fully accurate proxy for employment status, and there is potential for residual confounding. CONCLUSIONS: PD was associated with higher probabilities of maintaining and gaining employer-sponsored health insurance after dialysis initiation compared with IHD. These findings may inform policies that influence the uptake of PD, potentially improving rates of employer-sponsored health insurance and employment among dialysis recipients or their households. PLAIN-LANGUAGE SUMMARY: Unemployment remains a challenge for patients receiving maintenance dialysis. Furthermore, the impact of dialysis modality on employment loss and gain after dialysis initiation has not been well studied because of a lack of longitudinal measures of these outcomes. Using cause-specific hazards modeling and considering the loss or gain of employer-sponsored health insurance as a proxy for employment changes at the patient or household levels, we found that patients receiving peritoneal dialysis are less likely to lose and more likely to gain employer-sponsored health insurance than patients receiving in-center hemodialysis. These findings may inform policies that influence the uptake of peritoneal dialysis, potentially improving rates of employer-sponsored health insurance and employment among dialysis recipients or their households.