Outcomes in Vulnerable Populations Starting Dialysis: Informing Resource Allocation and Home Dialysis Targets

Background: Vulnerable populations are those who may be disadvantaged for medical or social reasons, and often experience health care disparities. Government mandated targets for home dialysis do not consider barriers such patients may face. We evaluated key performance indicators for patients starting chronic dialysis to inform resource allocation and home dialysis targets. Methods: All patients >=18 yo who started chronic dialysis for >=30 days from 2017-23 at our center were included. Vulnerable subgroups were defined a priori (indigenous, refugees, language barrier, age>=80). Data was extracted from electronic records and verified via manual chart review. We compared crash starts and 1-year outcomes using multi-level chi-square tests with post-hoc comparisons against non-vulnerable patients (NVP). Results: Of 693 patients, 241 (35%) were identified as being from a vulnerable subgroup (table 1). All outcomes except admission were significantly different between groups. Among refugees, 96% were crash starts (p<0.0001 vs NVP), and 0 started home dialysis (p=0.04 vs. NVP). Of patients >80yo, 32% died (p<0.0001 vs NVP), and only 2% transitioned to home dialysis (p=0.01 vs NVP). While home dialysis and mortality were similar for indigenous vs NVP, indigenous patients were significantly less likely to have kidney transplant or be referred for evaluation (p=0.002 vs NVP). Conclusion: Resource allocation should align with the needs of vulnerable subgroups based on observed outcomes. This includes increasing timely transplant referral for indigenous patients, prioritizing social interventions over home dialysis for refugees, and supporting appropriate end-of-life care in the elderly. Table 1 - Indigenous Refugees Lang Barrier Age ≥ 80 NVP Overall p N 138 26 24 53 452 Crash Start (74) 54% (25) 96%*** (11) 46% (25) 47% (239) 53% <0.001 Transplant Eval (32) 23%** n/a (8) 33% n/a (169) 37% <0.0001 Home Dialysis (19) 14% 0* (3) 13% (1) 2%* (65) 14% 0.031 Death (10) 7% (2) 8% (1) 4% (17) 32%*** (54) 12% <0.0001 Admission (83) 60% (11) 42% (10) 42% (30) 58% (262) 58% 0.248 Post-hoc comparisons vs. NVP: *p<0.05, **p<0.01, ***p<0.0001