1
|
Smith DJ, Mac V, Thompson LM, Plantinga L, Kasper L, Hertzberg VS. Using Occupational Histories to Assess Heat Exposure in Undocumented Workers Receiving Emergent Renal Dialysis in Georgia. Workplace Health Saf 2022; 70:251-258. [PMID: 35112607 DOI: 10.1177/21650799211060695] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immigrants often work in jobs that are known as dirty, demanding, and dangerous. Globally, the agricultural occupations have been associated with the emergence of chronic kidney disease of unknown etiology (CKDu) primarily in outdoor worker populations. The disease has also been reported in immigrants in the United States who work in agricultural occupations, but little research has been done outside of agricultural workers to determine whether immigrants who work other occupations are at risk for developing CKDu. METHODS This study assessed the self-reported occupational histories of undocumented immigrants receiving frequent, emergent-only dialysis in Atlanta, GA. We assessed demographics, employment status, and work history, using the Grady Dialysis Questionnaire and the Occupational/Environmental Health History Form. RESULTS Fifty undocumented immigrants receiving frequent, emergent-only hemodialysis were recruited for this study. The average age was 49.5 years (SD ± 11.5), and the majority (52%) were female and originated from Mexico (66%). A majority (74%) reported having worked in the past 5 years and 28% reported currently working. A total of 68 unique jobs were reported. In decreasing order of frequency, our sample worked in occupations with documented renal toxicant exposures, such as applying pesticides in landscaping, heat exposure in agriculture, construction, landscaping, and dry cleaning, and lead paint fumes in construction. DISCUSSION Occupational histories provide a greater understanding of the exposures and working conditions of those receiving frequent, emergent-only hemodialysis. This exploratory study suggests that further research is needed to investigate and assess whether renal toxicants are associated with occupations with high numbers of undocumented workers. APPLICATION TO PRACTICE A detailed and thorough occupational history should be conducted from those receiving frequent, emergent-only hemodialysis. Developing continuing education for nursing and medical staff in dialysis centers on taking an occupational history, mandatory State reporting requirements, and hazard communication training for workers should be considered. Collaborations between occupational health professionals, public health authorities, employers, dialysis providers, and clinicians who see undocumented workers is required to understand and develop appropriate prevention measures for this population.
Collapse
Affiliation(s)
- Daniel J Smith
- Emory University Nell Hodgson Woodruff School of Nursing
| | - Valerie Mac
- Emory University Nell Hodgson Woodruff School of Nursing
| | | | | | | | | |
Collapse
|
2
|
Mundo W, Platnick C, Rozwadowski J, Bruman W, Morton A, Pieracci FM. Providing access to affordable bariatric surgery for uninsured Denver County residents: description of a successful public health initiative. Surg Obes Relat Dis 2021; 17:994-999. [PMID: 33583733 DOI: 10.1016/j.soard.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 12/07/2020] [Accepted: 01/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Severe obesity disproportionately affects medically underserved communities. However, patients from these communities are the least likely to have access to affordable bariatric surgery. Few studies have described successful initiatives to mitigate this disparity. OBJECTIVES To describe the implementation of a public health initiative that provided affordable bariatric surgery to uninsured patients at our hospital. SETTING Denver Health Medical Center (DHMC), a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited safety-net hospital. METHODS Context regarding Denver city and county, DHMC, and bariatric surgery accreditation are provided, followed by a detailed description of the intervention. RESULTS Successful implementation of the initiative centered around: (1) MBSAQIP accreditation; (2) identification of existing institutional charity care programs, (3) enlistment of support/buy-in from key parties; (4) presentation of both general and institutional-specific outcome data following bariatric surgery to hospital administration; (5) framing of the argument as primarily financial, rather than moral; (6) delineation of initial volume and risk expectations; and (7) outcome monitoring. CONCLUSION We successfully provided access to affordable bariatric surgery for uninsured patients at our accredited safety-net hospital.
Collapse
Affiliation(s)
- William Mundo
- University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; University of Colorado Anschutz Medical Campus, School of Public Health, Aurora, Colorado.
| | - Carson Platnick
- University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
| | - Jeanne Rozwadowski
- Department of Primary Care, Denver Health Medical Center, Denver, Colorado
| | | | - Alex Morton
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
| |
Collapse
|
3
|
Luyckx VA, Al-Aly Z, Bello AK, Bellorin-Font E, Carlini RG, Fabian J, Garcia-Garcia G, Iyengar A, Sekkarie M, van Biesen W, Ulasi I, Yeates K, Stanifer J. Sustainable Development Goals relevant to kidney health: an update on progress. Nat Rev Nephrol 2020; 17:15-32. [PMID: 33188362 PMCID: PMC7662029 DOI: 10.1038/s41581-020-00363-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress. Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease. Each Sustainable Development Goal (SDG) has the potential to improve kidney health and prevent kidney disease by improving the general health and well-being of individuals and societies, and by protecting the environment. Achievement of each SDG is interrelated to the achievement of multiple other SDGs; therefore, a multisectoral approach is required. The global burden of kidney disease has been relatively underestimated because of a lack of data. Structural violence and the social determinants of health have an important impact on kidney disease risk. Kidney disease is the leading global cause of catastrophic health expenditure, in part because of the high costs of kidney replacement therapy. Achievement of universal health coverage is the minimum requirement to ensure sustainable and affordable access to early detection and quality treatment of kidney disease and/or its risk factors, which should translate to a reduction in the burden of kidney failure in the future.
Collapse
Affiliation(s)
- Valerie A Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa. .,Institute of Biomedical Ethics and the History of Medicine, University of Zürich, Zürich, Switzerland.
| | - Ziyad Al-Aly
- Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA.,Clinical Epidemiology Center, Veterans Affairs Saint Louis Health Care System, Saint Louis, MO, USA
| | - Aminu K Bello
- Division of Nephrology & Immunology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Raul G Carlini
- Sección de Investigación, Servicio de Nefrología y Trasplante Renal, Hospital Universitario de Caracas, Caracas, Venezuela
| | - June Fabian
- Wits Donald Gordon Medical Centre, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Witwatersrand, South Africa
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, University of Guadalajara Health Sciences Center, Hospital, 278, Guadalajara, Mexico
| | - Arpana Iyengar
- Department of Paediatric Nephrology, St. John's National Academy of Health Sciences, Bangalore, India
| | | | - Wim van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium
| | - Ifeoma Ulasi
- Renal Unit, Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Karen Yeates
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Stanifer
- Munson Nephrology, Munson Healthcare, Traverse City, MI, USA
| |
Collapse
|
4
|
Charnaya O, Verghese P, Goldberg A, Ladin K, Porteny T, Lantos JD. Access to Transplantation for Undocumented Pediatric Patients. Pediatrics 2020; 146:peds.2019-3692. [PMID: 32591437 DOI: 10.1542/peds.2019-3692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 11/24/2022] Open
Abstract
Clinicians in the United States today regularly face dilemmas about health disparities. Many patients and families cannot afford the medical care that doctors recommend. These problems are most stark when the medical care that is needed is lifesaving and expensive and involves scarce resources. Transplants are the best example of this. The most ethically disturbing situations occur when an undocumented immigrant child needs a transplant. We present such a case and analyze the ethical, legal, and policy issues that arise.
Collapse
Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Priya Verghese
- Division of Pediatric Nephrology, Department of Pediatrics, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Aviva Goldberg
- Section of Nephrology, Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Keren Ladin
- Research on Ethics, Aging, and Community Health Lab and.,Departments of Occupational Therapy and Community Health, School of Arts and Sciences, Tufts University, Medford, Massachusetts; and
| | | | - John D Lantos
- Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri
| |
Collapse
|
5
|
Hemodialysis care for undocumented immigrants with end-stage renal disease in the United States. Curr Opin Nephrol Hypertens 2020; 28:615-620. [PMID: 31403475 DOI: 10.1097/mnh.0000000000000543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Across the United States, significant variation exists in the provision of care of undocumented immigrants with end-stage renal disease (ESRD), with some states providing standard dialysis, and other states providing emergency-only hemodialysis (EoHD). RECENT FINDINGS EoHD is associated with higher morbidity and mortality compared with standard hemodialysis. EoHD is also associated with higher healthcare utilization, resulting in more emergency department visits, more days spent in the hospital, and higher healthcare costs. Undocumented immigrants with ESRD who rely on EoHD also experience crippling and potentially fatal physical symptoms as well as psychosocial suffering, with some patients describing recurrent near-death experiences. Clinicians who provide EoHD to undocumented patients report experiencing moral distress and symptoms of professional burnout because of providing care that they perceive as unethical and far below the standard of care. SUMMARY Undocumented immigrants with ESRD who rely on EoHD have worse health outcomes and quality of life compared with patients who receive standard hemodialysis. EoHD is also more costly to the healthcare system. Healthcare policy reform is critical as more research demonstrates the worse clinical outcomes and higher costs of EoHD.
Collapse
|
6
|
Lee BP, Terrault NA. Liver Transplantation in Unauthorized Immigrants in the United States. Hepatology 2020; 71:1802-1812. [PMID: 31487391 PMCID: PMC7103423 DOI: 10.1002/hep.30926] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/05/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS Eleven million unauthorized immigrants reside in the United States and may account for 3% of deceased organ donors. Recently introduced federal and state legislation propose to address access to organ transplantation among unauthorized immigrants. The national landscape of liver transplantation (LT) for unauthorized immigrants is unknown. APPROACH AND RESULTS We included all US LT recipients between March 2012 and December 2018 who were linked to Pew Center of Research data to estimate the population of unauthorized immigrants in each US state and by country of origin, based on US Census data. We categorized patients as unauthorized immigrants versus US citizens/residents. The main outcome measures were (1) the proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among total population in each US state and (2) graft failure and death post-LT. Of 43,192 LT recipients, 43,026 (99.6%) were US citizens/residents and 166 (0.4%) were unauthorized immigrants. Among unauthorized immigrants, most LTs were performed in California (47%) and New York (18%). The absolute difference in proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among the total population differed among states, ranging from +20% in California to -12% in Texas. The most common countries of birth among LT recipients who were unauthorized immigrants were Mexico (52%), Guatemala (7%), China (6%), El Salvador (5%), and India (5%). In competing risk analysis, unauthorized immigration status (vs. US citizens/residents) was associated with a similar risk of graft failure (subdistribution hazard ratio [sHR] 0.74; 95% confidence interval [CI], 0.40-1.34; P = 0.38) and death (sHR 0.68; 95% CI, 0.36-1.29; P = 0.23). CONCLUSIONS LT for unauthorized immigrants is rare, and disparities in access to LT by state are present. Patient and graft survival among unauthorized immigrants is comparable with citizens/residents.
Collapse
Affiliation(s)
- Brian P. Lee
- Department of Gastroenterology, University of California, San Francisco, San Francisco, CA
| | - Norah A. Terrault
- Department of Gastroenterology, University of Southern California, Los Angeles, CA
| |
Collapse
|
7
|
Welles CC, Cervantes L. Barriers to providing optimal dialysis care for undocumented immigrants: Policy challenges and solutions. Semin Dial 2020; 33:52-57. [DOI: 10.1111/sdi.12846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Christine C. Welles
- Department of Medicine Denver Health and Hospital Authority Denver CO USA
- Department of Medicine University of Colorado School of Medicine Aurora CO USA
| | - Lilia Cervantes
- Department of Medicine Denver Health and Hospital Authority Denver CO USA
- Department of Medicine University of Colorado School of Medicine Aurora CO USA
- Office of Research Denver Health and Hospital Authority Denver CO USA
| |
Collapse
|
8
|
Douthit NT, Old C. Renal Replacement Therapy for Undocumented Immigrants: Current Models with Medical, Financial, and Physician Perspectives-a Narrative Review. J Gen Intern Med 2019; 34:2246-2253. [PMID: 31388913 PMCID: PMC6816691 DOI: 10.1007/s11606-019-05237-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/12/2018] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
Renal replacement therapy is guaranteed for all US citizens with end-stage renal disease (ESRD). Undocumented immigrants with ESRD are a particularly vulnerable subset of renal failure patients. There is no federal legislation for these patients except for the requirement to treat them during "emergency medical conditions" and federal legislation excluding them from the guarantee of renal replacement therapy described above. Different states have developed different methods for dealing with this problem, with variation in management even addressed on a center by center basis. This review of the original studies published in the literature reveals the medical, ethical, and financial problems with this situation. These patients frequently have delayed presentation to care, poor access to routine care, increased complications, increased utilization of services, and increased morbidity and mortality in an emergent dialysis model compared to chronic outpatient care. They present an ethical dilemma for practitioners who know they are providing substandard care and occasionally making decisions on how to allocate resources. Emergent dialysis is associated with inadequate reimbursement, increased threat to sustained unemployment, and an overburdening of our healthcare infrastructure. This practice puts patients at risk, places an unfair ethical burden on providers and is financially unsustainable. Special considerations described for kidney transplant and peritoneal dialysis are considered and considerations for a new model are reviewed in the paper. Ultimately accommodations must be made with the input of government, healthcare practitioners, and facilities needs to be reached to protect these vulnerable patients.
Collapse
Affiliation(s)
- Nathan T Douthit
- Brookwood Baptist Health Medical Education, Birmingham, AL, USA.
| | - Christopher Old
- Brookwood Baptist Health Medical Education, Birmingham, AL, USA
| |
Collapse
|
9
|
Samra S, Taira BR, Pinheiro E, Trotzky-Sirr R, Schneberk T. Undocumented Patients in the Emergency Department: Challenges and Opportunities. West J Emerg Med 2019; 20:791-798. [PMID: 31539336 PMCID: PMC6754205 DOI: 10.5811/westjem.2019.7.41489] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 07/01/2019] [Indexed: 11/11/2022] Open
Abstract
In the United States, undocumented residents face unique barriers to healthcare access that render them disproportionately dependent on the emergency department (ED) for care. Consequently, ED providers are integral to the health of this vulnerable population. Yet special considerations, both clinical and social, generally fall outside the purview of the emergency medicine curriculum. This paper serves as a primer on caring for undocumented patients in the ED, includes a conceptual framework for immigration as a social determinant of health, reviews unique clinical considerations, and finally suggests a blueprint for immigration-informed emergency care.
Collapse
Affiliation(s)
- Shamsher Samra
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, California
| | - Breena R Taira
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | | | - Rebecca Trotzky-Sirr
- LAC-USC Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Todd Schneberk
- LAC-USC Medical Center, Department of Emergency Medicine, Los Angeles, California
| |
Collapse
|
10
|
Desai N, Lora CM, Lash JP, Ricardo AC. CKD and ESRD in US Hispanics. Am J Kidney Dis 2018; 73:102-111. [PMID: 29661541 DOI: 10.1053/j.ajkd.2018.02.354] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/08/2018] [Indexed: 12/23/2022]
Abstract
Hispanics are the largest racial/ethnic minority group in the United States, and they experience a substantial burden of kidney disease. Although the prevalence of chronic kidney disease (CKD) is similar or slightly lower in Hispanics than non-Hispanic whites, the age- and sex-adjusted prevalence rate of end-stage renal disease is almost 50% higher in Hispanics compared with non-Hispanic whites. This has been attributed in part to faster CKD progression among Hispanics. Furthermore, Hispanic ethnicity has been associated with a greater prevalence of cardiovascular disease risk factors, including obesity and diabetes, as well as CKD-related complications. Despite their less favorable socioeconomic status, which often leads to limited access to quality health care, and their high comorbid condition burden, the risk for mortality among Hispanics appears to be lower than for non-Hispanic whites. This survival paradox has been attributed to a complex interplay between sociocultural and psychosocial factors, as well as other factors. Future research should focus on evaluating the long-term impact of these factors on patient-centered and clinical outcomes. National policies are needed to improve access to and quality of health care among Hispanics with CKD.
Collapse
Affiliation(s)
- Nisa Desai
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Claudia M Lora
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - James P Lash
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago, Chicago, IL.
| |
Collapse
|