Barriers to employment for dialysis patients

Jobs are central to many of our political conversations. Measures like the unemployment rate are good indicators of the overall health of our economy, and work is frequently debated in the context of eligibility requirements for state and federal assistance programs like welfare and Medicaid.

But many factors can impact an individual’s ability to become and remain employed. Understanding specific challenges people face to finding work can help us target resources appropriately to keep people in the workforce.

We recently explored this topic in the context of dialysis patients. End-stage renal disease (ESRD) is unique because it is the only health condition that automatically qualifies people for Medicare regardless of their age – a result of 1972 Social Security Amendments signed into law by then President Nixon.

At the time the law was passed, the bill’s supporters argued that access to life-sustaining dialysis therapy would enable patients to continue being productive members of society through work and activities at home.

While the law successfully provided access to dialysis therapy for many patients who would have otherwise died from kidney failure, it has been less successful at helping patients to continue working.

Part of the problem stems from the nature of dialysis treatment. Every year nearly 125,000 adults in the United States develop ESRD. The majority of these individuals are unable to receive a kidney transplant and must undergo life-long dialysis therapy in order to stay alive.

Dialysis therapy requires frequent treatments – at least three times per week – which usually last several hours. The time and physical toll that dialysis treatments can have on patients makes employment difficult.

However, many patients with advanced kidney disease face significant health challenges even before they require dialysis therapy, including frequent hospitalizations, fatigue, and cardiovascular disease. It is unknown whether these challenges are also important drivers of unemployment.

To examine this question, we conducted a study using data from a national registry of patients with ESRD to examine trends in employment between 1996 and 2013 among patients starting dialysis and in the six months before starting dialysis.

Notably, more than three-quarters of patients were not working by the time they started dialysis, and about a third of patients who were employed six months prior to starting dialysis had stopped working by the time they progressed to ESRD.

This means that in addition to the time-intensive dialysis treatments affecting employment, patients with ESRD face significant barriers to employment in the period before they even begin dialysis. This finding could have important policy implications.

For example, dialysis facilities in the United States are required to ask patients regularly about their employment status and to assist those who wish to work in accessing vocational rehabilitation. Low employment among patients receiving dialysis suggests that, in many instances, this may be more of a formality.

Perhaps it’s because we are reaching these patients too late. Our findings indicate that efforts to help patients remain employed must also focus on helping patients before they progress to ESRD. How we do this, however, is not clear.

Helping patients stay employed has long been an important goal of the U.S. ESRD program, and with good reason. For some patients, employment is associated with improved quality of life and an increased sense of physical and mental wellbeing.

If low employment is a problem for patients even before starting dialysis, we need to find opportunities to target resources more effectively. By highlighting the timing and severity of low employment in the dialysis population, I hope this study will renew efforts to help patients with ESRD find work.

-By Dr. Kevin Furman Erickson, assistant professor of medicine, section of nephrology at Baylor College of Medicine and health policy scholar in the Center for Medical Ethics and Health Policy

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