Factors Affecting Employment at Initiation of Dialysis

Discussion

The purpose of this study was to examine 10 years of data from the USRDS to identify nonmodifiable and modifiable factors affecting a person's ability to maintain their level of employment after initiating dialysis. Our study found that white men between the ages of 18 and 55 years were most likely to retain the same level of employment. In contrast, women, non-Caucasians, and those who were Hispanic were less likely to retain the same level of employment. Given the inherent limitations of the USRDS database, further studies are needed to better understand other factors that may also be contributing to an inability to maintain employment such as socioeconomic status and education level. A better understanding of these factors will help researchers and clinicians develop more effective interventions to help individuals maintain employment.

Inability to ambulate and stroke were the comorbidities most likely to render a person unable to maintain the same level of employment. We also found that individuals who had more comorbid conditions were less likely to maintain employment. Finally, we found that having combinations of certain comorbid conditions further decreased a person's ability to maintain employment. For example, a person with both congestive heart failure and ischemic heart disease would have an odds ratio of 0.72 (OR 0.79 × OR = 0.91) for maintaining employment versus a person with neither condition. It is interesting to note that the presence of diabetes (both insulin- and non–insulin-dependent) did not affect a person's ability to maintain employment. One possible explanation for this finding is that individuals with more severe diabetic complications had already stopped working earlier in the course of their kidney disease. Therefore, they may not have been included in our sample.

Our study found that persons who were treated with EPO for anemia, persons who chose peritoneal dialysis as their primary dialysis modality, and persons who had an employer group health plan as their primary payer were more likely to maintain the same level of employment at initiation of dialysis.

Patients treated with EPO for anemia were more likely to maintain their employment. This is probably due to the improvement of fatigue and well-being reported by ESRD patients treated with erythropoietin (11). Despite the increasing knowledge of the association of advanced CKD and anemia (12), it is unfortunate that only 28.4% of our sample of working-age patients received EPO before dialysis initiation. Furthermore, because of the number of persons receiving EPO in our sample increased only by 6.1% after the 1997 KDOQI anemia guidelines were published, it appears that they did not significantly affect the number of persons being treated for anemia. Results from our study suggest that treating anemia when clinically indicated may help more people retain their employment. However, additional research is needed to clarify the optimal degree of anemia correction that can be safely implemented to optimize patient outcomes including maintaining employment.

Patients in our study who had maintained the same level of employment during the last 6 months before kidney failure were significantly more likely to choose PD as their initial treatment modality. In contrast, those who had not retained the same level of employment from 6 months before kidney failure were more likely to choose HD. Although it could be argued that those chose PD were more educated and more motivated to keep their employment, this finding is consistent with findings from previous studies (13,14). In general, PD allows more flexibility and control over one's treatment schedule and is associated with higher patient satisfaction than in-center hemodialysis (15,16). Despite these advantages, declining numbers of patients are initiating peritoneal dialysis (17) (18). The reasons for the decline are likely multifactorial. There is some concern of possible decreased survival (19,20) and increased risk of complications for certain patients (21). Other possible reasons for this decline are more systems related. In general, outpatient dialysis centers are primarily structured to deliver in-center HD care. Finally, many patients do not receive enough education regarding PD before kidney failure (22).

Ensuring that working-age patients are offered PD could be one means of helping them maintain employment. However, there are other options such as accommodating the work schedules of in-center HD patients or offering and promoting home hemodialysis. It was recently reported that dialysis centers offering later dialysis shifts (after 5:00 p.m.) and/or home HD training had higher employment rates than facilities that did not offer these options (14). Unfortunately, because of the very small number of people in our sample on home hemodialysis as well as the lack of data specific to dialysis shifts, we were unable to examine these factors.

The final factor associated with maintaining employment was having an employer group health plan or other insurance as a primary payer. Patients with Medicaid or Medicare as a primary payer or patients with no insurance were least likely to maintain employment. In general, patients with employer group health insurance or other insurance have access to better health care. Patients with access to better health care have fewer comorbid conditions and are at a lower risk of hospitalization after reaching kidney failure (23).

We recognize a likely association between type of health insurance and EPO use. Therefore, we examined this relationship in a post hoc analysis (Table 6). We found that persons with employer group coverage or other insurance were more likely to have been treated with EPO (Table 6). In contrast, patients with Medicaid or Medicare, both of which cover EPO for anemia of CKD, or no insurance were less likely to be prescribed EPO. We believe EPO treatment is one of the factors that allowed patients to maintain the same level of employment by decreasing their fatigue and risk of hospitalization. Further study of this relationship is warranted.

We acknowledge some potential limitations to our study. This study reflects a retrospective analysis of data from the USRDS on patients starting treatment for ESRD in the time frame 1992 through 2003. Because of its retrospective design, we can only report associations between variables. We cannot demonstrate cause and effect. Also, we were limited by the variables that we were able to analyze because of the limited data collected by the CMS 2728 form. For example, previous facility-based studies have noted that higher levels of education are associated with greater likelihood of employment in patients with kidney failure (9). Because the CMS 2728 form does not collect data on education or socioeconomic level, we were unable to assess this relationship. We were also unable to account for center effects. A second limitation is the CMS 2728 form did not include data about comorbidities until 1995, which limits our data analysis for those years. A third limitation was the lack of patient-specific data available after dialysis began. Therefore, we were unable to determine if these factors remained significant or worsened after dialysis initiation as has been noted in other studies (24). Finally, we were unable to assess the reliability of the data collection as there is no consistent protocol for who completes the CMS 2728 forms across dialysis centers and the potential biases that may have occurred in the data collection process.

In conclusion, unemployment affects up to 75% of incident ESRD patients (5). This rate increases with time on dialysis (24). Unemployment in working-age adults is associated with greater physical and psychological problems (6) and loss of self-esteem (7). It also places an enormous economic burden on society. In 1972, Congress established the Medicare End-Stage Renal Disease program with the expectation that payment for dialysis would return patients to the work force as taxpaying citizens. However, Congress did not anticipate growth in this patient population, changing demographics, nor escalating costs to Medicare. Helping working-age patients keep their jobs offers the opportunity to offset societal costs and reduce the financial burden to Medicare and private disability programs. Further research is needed to determine whether interventions based on the findings of our study would be effective in helping patients with advancing chronic kidney disease maintain employment. Finally, the effect of job loss on ESRD patients and their families as well as the effect on government run programs such as Medicare needs further analysis.