Provision of Temporary Access to Inpatient Hemodialysis to Uninsured Patients Initiating Hemodialysis

Importance: Uninsured patients who initiate hemodialysis (HD) typically cannot be placed in outpatient HD centers until their insurance applications are processed. Allowing these patients temporary access to an inpatient HD unit as outpatients could shorten their hospital length of stay (LOS). Objective: To evaluate the association of hospital LOS with a first-in-state model in which an inpatient HD unit received regulatory program flex approval to provide temporary, transitional outpatient access to uninsured patients. Design, Setting, and Participants: This quasi-experimental, pre-post quality improvement study was conducted at 1 intervention hospital and 2 control hospitals within the safety net of the Los Angeles County Department of Health Services among uninsured inpatients who newly initiated HD from January 1, 2016, through December 31, 2024. Exposure: Transitional outpatient HD access to an inpatient unit was implemented in February of 2020 at the Los Angeles General Medical Center (LA General). Control hospitals began to use their emergency departments for outpatient HD access during the intervention period. Main Outcomes and Measures: The primary outcome measure was the difference in LOS before vs after transitional HD implementation. Secondary outcomes included all-cause 30-day readmission and mortality rates. Results: Overall, 951 patients were included in this study. In the preintervention period, LA General treated 200 uninsured inpatients newly initiating HD (mean [SD] age, 52.0 [11.7] years; 130 men [65.0%]) vs 241 patients (mean [SD] age, 52.9 [11.1] years; 171 men [71.0%]) in the postintervention period. The mean (SD) LOS at LA General was significantly shorter after vs before the intervention (7.6 [6.6] vs 13.0 [17.5] days; P < .001). At control hospitals, 234 patients (mean [SD] age, 52.4 [13.6] years; 164 men [70.1%]) were treated in the preintervention period, and 276 patients (mean [SD] age, 52.7 [12.5] years; 209 men [75.7%]) were treated in the postintervention period. The mean (SD) LOS at control hospitals was significantly shorter after vs before the intervention (9.1 [9.4] vs 12.5 [15.3] days; P = .002). Difference-in-difference analysis did not demonstrate a reduction in LOS at LA General vs control hospitals (-2.0 days; P = .23). However, run charts demonstrated immediate, sustained reductions in LOS at LA General but variations in LOS after the intervention at the control hospitals, such that the parallel trends assumption for difference-in-difference validity was likely not met. Conclusions and Relevance: In this quality improvement study, regulatory approval of an inpatient HD unit to provide transitional, outpatient services to uninsured patients newly initiating HD was associated with a significantly reduced LOS. These results suggest that this model could be a viable solution for other hospitals facing similar difficulties with expeditious discharge planning for uninsured patients undergoing HD.