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COVID-19 Risk Factors and Mortality Outcomes Among Medicare Patients Receiving Long-term Dialysis

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Key Points

Question  What are the characteristics and mortality outcomes associated with COVID-19 among Medicare patients undergoing long-term dialysis?

Findings  This cohort study among 498 169 patients receiving regular maintenance dialysis found several risk factors for COVID-19 that persisted as risk factors for mortality: nursing home status, time on dialysis, congestive heart failure, diabetes, and comorbidity burden. Higher COVID-19 rates were observed among Black patients, while attenuated survival differences were observed between Black and non-Black patients, and although male sex was not associated with a higher COVID-19 rate, it was associated with higher mortality among patients with COVID-19.

Meaning  These findings suggest that among patients undergoing long-term dialysis, Black race, male sex, nursing home status, and having comorbidities, such as diabetes and cardiac diseases, were associated with higher risk of COVID-19 and higher post–COVID-19 mortality.


Importance  There is a need for studies to evaluate the risk factors for COVID-19 and mortality among the entire Medicare long-term dialysis population using Medicare claims data.

Objective  To identify risk factors associated with COVID-19 and mortality in Medicare patients undergoing long-term dialysis.

Design, Setting, and Participants  This retrospective, claims-based cohort study compared mortality trends of patients receiving long-term dialysis in 2020 with previous years (2013-2019) and fit Cox regression models to identify risk factors for contracting COVID-19 and postdiagnosis mortality. The cohort included the national population of Medicare patients receiving long-term dialysis in 2020, derived from clinical and administrative databases. COVID-19 was identified through Medicare claims sources. Data were analyzed on May 17, 2021.

Main Outcomes and Measures  The 2 main outcomes were COVID-19 and all-cause mortality. Associations of claims-based risk factors with COVID-19 and mortality were investigated prediagnosis and postdiagnosis.

Results  Among a total of 498 169 Medicare patients undergoing dialysis (median [IQR] age, 66 [56-74] years; 215 935 [43.1%] women and 283 227 [56.9%] men), 60 090 (12.1%) had COVID-19, among whom 15 612 patients (26.0%) died. 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%]), as well as patients with short (ie, 1-89 days; 7738 of 55 184 patients [14.0%]) and extended (ie, ≥90 days; 10 737 of 30 196 patients [35.6%]) nursing home stays in the prior year. Adjusting for all other risk factors, residing in a nursing home 1 to 89 days in the prior year was associated with a higher hazard for COVID-19 (hazard ratio [HR] vs 0 days, 1.60; 95% CI 1.56-1.65) and for postdiagnosis mortality (HR, 1.31; 95% CI, 1.25-1.37), as was residing in a nursing home for an extended stay (COVID-19: HR, 4.48; 95% CI, 4.37-4.59; mortality: HR, 1.12; 95% CI, 1.07-1.16). Black race (HR vs non-Black: HR, 1.25; 95% CI, 1.23-1.28) and Hispanic ethnicity (HR vs non-Hispanic: HR, 1.68; 95% CI, 1.64-1.72) were associated with significantly higher hazards of COVID-19. Although home dialysis was associated with lower COVID-19 rates (HR, 0.77; 95% CI, 0.75-0.80), it was associated with higher mortality (HR, 1.18; 95% CI, 1.11-1.25).

Conclusions and Relevance  These results shed light on COVID-19 risk factors and outcomes among Medicare patients receiving long-term chronic dialysis and could inform policy decisions to mitigate the significant extra burden of COVID-19 and death in this population.

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Article Information

Accepted for Publication: September 20, 2021.

Published: November 17, 2021. doi:10.1001/jamanetworkopen.2021.35379

Correction: This article was corrected on June 8, 2022, to fix the figure keys in Figure 1.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Salerno S et al. JAMA Network Open.

Corresponding Author: Yi Li, PhD, Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ste 3645 SPH I, Ann Arbor, MI 48109 (yili@umich.edu).

Author Contributions: Dr Li had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Salerno, Messana, Gremel, Dahlerus, Hirth, Segal, Shaffer, Shearon, Borowicz, Agbenyikey, Li.

Acquisition, analysis, or interpretation of data: Salerno, Messana, Gremel, Dahlerus, Hirth, Han, Xu, Jiao, Simon, Tong, Wisniewski, Nahra, Padilla, Sleeman, Shearon, Callard, Yaldo, Agbenyikey, Horton, Roach, Li.

Drafting of the manuscript: Salerno, Messana, Gremel, Hirth, Sleeman, Callard, Borowicz, Agbenyikey, Horton, Li.

Critical revision of the manuscript for important intellectual content: Salerno, Gremel, Dahlerus, Han, Segal, Xu, Shaffer, Jiao, Simon, Tong, Wisniewski, Nahra, Padilla, Shearon, Yaldo, Agbenyikey, Roach, Li.

Statistical analysis: Salerno, Gremel, Hirth, Shaffer, Jiao, Simon, Agbenyikey, Li.

Obtained funding: Messana, Hirth, Roach, Li.

Administrative, technical, or material support: Messana, Gremel, Padilla, Sleeman, Callard, Yaldo, Borowicz, Agbenyikey, Horton, Li.

Supervision: Messana, Segal, Agbenyikey, Roach, Li.

Conflict of Interest Disclosures: Drs Dahlerus, Han, Segal, Shaffer, Nahra, and Li and Mr Salerno, Mr Gremel, Ms Jiao, Mr Simon, Ms Tong, Ms Wisniewski, Ms Padilla, Ms Shearon, Ms Callard, and Mr Yaldo reported receiving grants from the Centers for Medicare & Medicaid Services (CMS) outside the submitted work. No other disclosures were reported.

Funding/Support: This work was funded by the CMS (contract No. 75FCMC18D0041; task order No. 75FCMC18F0001).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation or approval of the manuscript; and decision to submit the manuscript for publication. The CMS did review the manuscript prior to submission for publication.

Disclaimer: The statements in this study are solely the responsibility of the authors and do not necessarily represent the views of CMS. Data were obtained from CMS under the contract and associated Data Use Agreement.

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Mathur  R , Rentsch  CT , Morton  CE ,  et al; OpenSAFELY Collaborative.  Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform.   Lancet. 2021;397(10286):1711-1724. doi:10.1016/S0140-6736(21)00634-6 PubMedGoogle ScholarCrossref
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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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