title: Association between lack of health insurance and risk of death and ESRD: results from the Kidney Early Evaluation Program (KEEP).
abstract: BACKGROUND
  Uninsured adults in the United States have poor access to health care services and worse health outcomes than insured adults. Little is known about the association between lack of insurance and chronic kidney disease (CKD) progression to end-stage renal disease (ESRD) or death in patients at high risk of kidney disease. We used 2000-2011 data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) to examine this association.
  
  
  METHODS
  The study population included KEEP participants younger than 65 years. Outcomes were time to ESRD (chronic kidney failure treated by renal replacement therapy) and time to death. Incident ESRD was ascertained by linkage to the US Renal Data System, and vital status, by linkage to the Social Security Administration Death Master File. We used Cox proportional hazard regression to examine the association between insurance and risk of death or ESRD after adjusting for demographic variables.
  
  
  RESULTS
  Of 86,588 participants, 27.8% had no form of insurance, 10.3% had public insurance, and 61.9% had private insurance; 15.0% had CKD (defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2) or urine albumin-creatinine ratio ≥ 30 mg/g), 63.3% had hypertension, and 27.7% had diabetes. Of participants with CKD, 29.3% had no health insurance. Participants without insurance were younger, more likely to be Hispanic and to have 12 or fewer years of education, and less likely to have seen a physician in the past year. After adjustment for demographic characteristics, uninsured KEEP participants were 82% more likely than privately insured participants to die (HR, 1.82; 95% CI, 1.56-2.12; P < 0.001) and 72% more likely to develop ESRD (HR, 1.72; 95% CI, 1.33-2.22; P < 0.001). The association between insurance and outcomes varied by CKD stage.
  
  
  CONCLUSIONS
  Lack of insurance is an independent risk factor for early death and ESRD in this population at high risk of kidney disease. Considering the high morbidity and mortality and increasing cost associated with ESRD, access to appropriate health insurance coverage is warranted.
authors.affiliation: Christiana Care Center for Outcomes Research, Christiana Care Health System, Newark, DE 19718, USA. cjurkovitz@christianacare.org
authors.forename: Claudine T
authors.initials: CT
authors.lastname: Jurkovitz
authors.forename: Suying
authors.initials: S
authors.lastname: Li
authors.forename: Keith C
authors.initials: KC
authors.lastname: Norris
authors.forename: Georges
authors.initials: G
authors.lastname: Saab
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Bomback
authors.forename: Adam T
authors.initials: AT
authors.lastname: Whaley-Connell
authors.forename: Peter A
authors.initials: PA
authors.lastname: McCullough
mesh_terms: D000328:Adult; D003710:Demography; D018450:Disease Progression; D005260:Female; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006801:Humans; D007348:Insurance, Health / Q000145:classification / Q000706:statistics & numerical data; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy; D007677:Kidney Function Tests / Q000379:methods; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D009026:Mortality; D016730:Program Development; D016016:Proportional Hazards Models; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology