Panel Discussion on Health Disparities Denyse Thornley-Brown, M.D. Associate Professor, Division of Nephrology, UAB

Objective To present some of the ethical issues related to health disparities using the case of an undocumented immigrant in need of dialysis.

Outline Background information: End stage renal disease in the U.S. Changes in population demographics in Alabama. Review the sequence of events with input from the panel.

ESRD in the US: ,982 patients requiring life-saving treatment for end stage renal disease (ESRD): 48% (265,639) kidney transplantation 52% (382,343) dialysis United States Renal Data System (USRDS) 2010 Annual Data Report

Annual Cost of ESRD USRDS 2010 Annual Data Report $billions Medicare26.80 Non-Medicare12.66 TOTAL39.46

Medicare Spending Medicare spending per patient year 2008 Overall: $65,891 Range: $26,668-$77,506 USRDS 2010 Annual Data Report

Dialysis Clinic Ownership Adapted from USRDS 2010 Annual Data Report

Summary ESRD is a fatal disorder without dialysis or kidney transplantation. Cost of treatment is high. Medicare covers 80% of dialysis costs and 80% of the costs of the first 3 years post renal transplantation. Most patients dialyze in for profit clinics.

Changes in Alabama Demographics

Rate of growth of Hispanic population second only to South Carolina. Approximately 186,000 Hispanics lived in AL at time of 2010 census. Alabama ranks 33rd among states in terms of Latino population.

Undocumented Immigrants in Alabama Adapted from Pew Hispanic Center 2/1/11 Report, Unauthorized Immigrant Populations: National and State Trends, 2010 Estimated PopulationRange 19905, , , , , , ,000

Initial Presentation 23 year old previously healthy Latino man presented to the emergency room with a 3 month history of nausea, vomiting and abdominal pain. Had been seen in a clinic and given famodipine without improvement. Social history: undocumented immigrant from Latin America; moved to Alabama at age 13; no tobacco, ETOH or drug use.

Physical Exam and Labs Blood pressure 140/81; pulse 79. Physical examination unremarkable. BUN 208 mg/dL, serum creatinine 31.3 mg/dL, consistent with advanced kidney failure. Hematocrit 13% indicating severe anemia.

Hospital Course Admitted to the hospital. Kidney ultrasound: small kidneys, consistent with ESRD and no possibility of recovery of kidney function.

Should dialysis therapy be offered to this patient? 2. If so, who should pay for it?

Hospital Course Dialysis initiated through a temporary catheter. Patient responded to treatment and was feeling better. Attempts at obtaining treatment at an outpatient dialysis clinic were unsuccessful due to uninsurability.

What are the ethical obligations of the treating physicians at this point? 2. What are the ethical obligations of the hospital?

Medicaid Medicaid is a federally funded, state run program for the poor. Approximately ten states provide Medicaid coverage for undocumented immigrants in need of dialysis. Alabama does not. Is it ethical to provide the patient with a list of states that provide Medicaid for undocumented immigrants?

Hospital Course (contd) Each month, the patient had a different attending physician. Surgeon placed a permanent dialysis access at the request of the treating physician. Patient remained in the hospital for three months because an outpatient slot could not be obtained.

Additional History Patient has 5 healthy siblings, all living in Alabama. Attending physician starts investigating the possibility of kidney transplantation.

Assuming that the hospital agrees to transplant the patient, what are the ethical issues involved in investigating his siblings as potential kidney donors?

After three months in the hospital, a new physician takes over. The patient is discharged from the hospital and told to return to the emergency room if he feels the need for dialysis. Hospital Course

In view of difficulty obtaining dialysis services for undocumented immigrants, how should physicians counsel clinic patients with chronic kidney disease who are not yet in need of dialysis?

Follow up He has not been able to get a kidney transplant. He has had at least 29 emergency visits in one year, most of which have resulted in admission for emergency dialysis.

Follow up (contd) Three other undocumented immigrant patients were hospitalized at the same time as this patient. Two moved to states providing emergency Medicaid. One returned to Latin America where he eventually died for lack of funds to cover dialysis.

Questions or Comments?