Background: People on hemodialysis are hospitalized frequently but some are hospitalized more than others. Food insecurity, housing instability, and substance use disorder are risk factors for chronic kidney disease progression that may explain disparities in hospitalization risk among people on hemodialysis. They may also impact health-related quality of life, a patient-reported outcome associated with acute care utilization.
Objectives: This dissertation study examined relationships between individual and area-level indicators of socioeconomic position; food insecurity, housing instability, and substance use disorder (framed as contextual risk factors); and hospitalization and quality of life among people on hemodialysis.
Methods: We enrolled a convenience sample of 322 people receiving hemodialysis at facilities in the Baltimore and Washington, D.C. metropolitan areas from February through December 2021. Using baseline survey data, we conducted multivariate and mixed effects logistic regression to test associations between (1) individual and area-level indicators of socioeconomic position and (2) food insecurity and housing instability (aim one). Using electronic medical record data from 6 months of study follow up, we applied Cox regression and multivariate linear regression models to test associations between (1) baseline contextual risk factors (i.e., food insecurity, housing instability, or substance use disorder) and (2) hospitalization and quality of life among people on hemodialysis.
Results: Over 30% of participants experienced food insecurity in the previous 12 months. 18% reported housing instability. People experiencing food insecurity were more likely to report moderate or high-risk use of tobacco and cannabis or other drugs. Younger age was a risk factor for food insecurity and housing instability. Additionally, residential segregation moderated associations between age, gender, and food security (aim one). Food insecurity, housing instability, and moderate or high-risk substance use were not associated with all-cause hospitalization. However, food insecurity was associated with missed hemodialysis treatments, hospitalizations due to fluid overload or hyperkalemia, and poor kidney disease-related quality of life (aim two).
Conclusions: Contextual risk factors, particularly food insecurity, impact health outcomes across the trajectory of chronic kidney disease and are common among people on hemodialysis. Stakeholders can address food insecurity among people on hemodialysis now while health equity research in chronic kidney disease continues
