Transportation Insecurity and Outcomes in Hemodialysis Patients: A Retrospective Cohort Study.

BACKGROUND

Transportation insecurity for people with end stage kidney disease (ESKD) treated with in-center hemodialysis (HD) may be a modifiable social risk that if addressed could improve access to dialysis treatments and lower mortality and complications associated with ESKD.

METHODS

Retrospective, national cohort study between April 1, 2022 through March 31, 2023. The study included all adults with ESKD receiving in-center HD within a large dialysis organization for at least 90 days prior to April 1, 2022 and having completed at least one transportation assessment. Primary outcomes were missed dialysis treatments and mortality. Primary exposure was the mode of transportation to dialysis.

RESULTS

In this study, 115,982 individuals (mean age 63 years, 43% female, 74% residing in urban setting) met the inclusion criteria. Nearly one-third (27%) did not have private transportation, defined as driving themselves or having a friend or family member drive them to dialysis. All individuals who lacked private transportation had higher mortality at one-year follow-up compared to those with private transportation: adjusted Incident Rate Ratio (aIRRs) (95%CI's) 1.25 (1.19-1.30), 1.21 (1.15-1.28), 1.70 (1.55-1.86), and 1.09 (1.02-1.17) for Medicaid, paratransit (available for individuals with a disability or a disabling health condition), private pay non-emergency medical transportation, and public transit, respectively. Medicaid, paratransit, and public transportation users were more likely to miss dialysis treatments compared to those with a private ride: aIRRs (95%CIs) 1.31 (1.27-1.35), 1.15 (1.11-1.20), and 1.24 (1.18-1.30), respectively. All non-private transportation users had higher likelihood of missed dialysis treatments attributed to transportation: aIRRs (95%CIs) 2.78 (2.62-2.94), 2.55 (2.35-2.76), 1.83 (1.58-2.12), and 2.73 (2.47-3.01) for Medicaid, paratransit, private pay non-emergency medical transportation, and public transit, respectively.

CONCLUSION

A lack of private transportation was associated with higher risk of missed dialysis treatments and mortality in adults with ESKD treated with in-center HD.