End-stage renal disease (ESRD) patients receiving long-term dialysis are believed to be at higher risk for SARS-CoV-2 and for death following infection, but a cohort analysis suggests that other factors, including race and comorbidities, may be driving that elevated risk.
Nursing home residence, Black race, and comorbid diabetes were all associated with higher incidence of Covid-19 and mortality following Covid-19 diagnosis in the study, which included data on all Medicare ESRD patients on long-term dialysis in 2020.
The analysis of data on close to half a million people revealed that just over 60,000 of the ESRD patients on dialysis developed Covid-19 during the period (12.1%), and more than a quarter of those patients (26%) died, Stephen Salerno, MS, of the University of Michigan, Ann Arbor, and colleagues reported in JAMA Network Open.
Compared to non-Black patients, Covid-19 rates were significantly higher among Black and Hispanic patients (13.1% and 15.6%, respectively), and extended residence in a nursing home was associated with a more than 4-fold increase in mortality.
“To our knowledge, this cohort study is the first national study using CMS claims data to evaluate Covid-19 outcomes in the Medicare dialysis population using all available 2020 data through December 2020,” Salerno and colleagues wrote.
The researchers noted that around 70% of ESRD patients in the U.S. are on long-term dialysis, and prior research has shown these patients to have a higher risk for Covid-19 infection, “as treatment necessitates frequent visits to outpatient dialysis units.”
The investigators conducted a retrospective, claims-based cohort study comparing mortality trends among patients on long-term dialysis in the year 2020 against overall mortality trends for the years 2013 through 2019.
They used Cox regression modeling to identify risk factors for SARS-CoV-2 infection and mortality following a Covid-19 diagnosis. Primary study outcomes included Covid-19 infection and all-cause mortality, and associations between claims-based risk factors and Covid-19 and mortality were analyzed.
Among a total of 498,169 Medicare patients undergoing dialysis (median age, 66 years; 56.9% male; 33.3% Black, 66.7% non-Black), 60,090 (12.1%) developed Covid-19 in 2020, and 15,612 of these patients (26.0%) died.
The analysis revealed that:
- Covid-19 rates were significantly higher among Black (21,787 of 165,830 patients [13.1%]) and Hispanic (13,530 of 86,871 patients [15.6%]) patients, compared with non-Black patients (38,303 of 332,339 [11.5%]).
- Adjusting for all other risk factors, nursing home residence for 89 days or less in 2019 was associated with a higher hazard for Covid-19 (hazard ratio [HR] versus 0 days, 1.60; 95% CI 1.56-1.65) and for death following a diagnosis of Covid-19 (HR, 1.31; 95% CI, 1.25-1.37).
- Black race (HR versus non-Black: HR, 1.25; 95%CI, 1.23-1.28) and Hispanic ethnicity (HR versus non-Hispanic: HR, 1.68; 95% CI, 1.64-1.72) were associated with significantly higher Covid-19 hazard.
Compared to receiving dialysis at a remote center, home dialysis was associated with a lower risk for Covid-19, (HR, 0.77; 95% CI, 0.75-0.80), but a higher mortality risk (HR, 1.18; 95% CI, 1.11-1.25).
The findings confirmed that mortality patterns among long-term dialysis patients in the U.S. during 2020 “deviated from historical trends both overall and with respect to race, sex, and area of residence,” the researchers wrote.
“Importantly, we identified nursing home residence to be a significant risk factor associated with Covid-19 and subsequent death,” they noted. “Previous studies reported that nursing home residents comprising less than 5% of the population accounted for about 25% of Covid-19 related deaths nationwide. We estimated a 36% Covid-19 rate and 12% higher mortality among patients with extended stays versus patients with no prior time in a long-term care or skilled nursing facility. The nursing home experience during the pandemic appears to be particularly salient among the dialysis population, potentially owing to congregate living, the inability to socially distance, and higher frailty and comorbidity burden among nursing home residents.”
Study limitations include that all events during follow-up may not yet be observed due to delays in Medicare claims processing; difficulty in determining an exact infection date for patients; and the challenge of capturing Covid-19 cases early in the pandemic.
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An analysis of nationwide Medicare data identified Covid-19 risk factors driving mortality in end-stage renal disease (ESRD) patients.
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Nursing home residence, Black race, and comorbid diabetes all contributed to higher incidence of Covid-19 infection and Covid-19–related mortality among ESRD patients.
Salynn Boyles, Contributing Writer, BreakingMED™
This work was funded by the Center for Medicare & Medicaid Services (CMS).
Several researchers reported receiving CMS grants for work unrelated to this study. No other disclosures were reported.
Cat ID: 190
Topic ID: 79,190,730,933,190,926,127,472,192,927,463,928,925,934
