Barriers from COVID-19 in Home Dialysis Use among Patients with ESKD and Disability

Background: Home dialysis offers numerous patient-centered and economic benefits for patients with ESRD. Despite advancements in federal policy initiatives, only 13.4% of patients with ESRD dialyze at home in the US. Home dialysis is an optimal treatment modality for ESRD patients with disabilities who have increased challenges in activities of daily living. As COVID-19 exacerbated access challenges across healthcare settings, we hypothesized that disabled ESRD patients may utilize home dialysis to a lesser degree post-pandemic compared to prior to the pandemic. Methods: We used 100% Medicare Fee-For-Service (FFS) claims data to identify patients with ESRD who initiated in-center renal replacement therapy (hemodialysis) between July 1, 2017 and September 30, 2017 (Pre-Pandemic Cohort) or between July 1, 2021 and September 30, 2021 (Post-Pandemic Cohort) and maintained in-center hemodialysis for at least three months from their initial visit. Among these patients, we identified those who transitioned to home peritoneal dialysis within 18 months following the 3-month period of in-center hemodialysis. We stratified beneficiaries by their original reason for Medicare entitlement. Results: After COVID-19, the relative proportion of disabled Medicare FFS beneficiaries who initiated home hemodialysis decreased from 34.5% in the Pre-Pandemic Cohort to 25.9% in the Post-Pandemic Cohort (p<0.001). There were no statistically significant differences between the cohorts in age, dual status, race, sex, or beneficiary state. Conclusion: Findings suggest that COVID-19 exposed a multi-layered disparity, exacerbating access barriers in the healthcare delivery system for patients with both ESRD and disabilities. Future research and policy should focus on increased support for dialysis patients with disabilities, ensuring equitable access to treatment modalities.Figure 1: Distribution of Original Reason for Medicare Entitlement among Medicare FFS ESRD Patients Initiating Home Dialysis Service