Clinical outcomes and healthcare utilization in patients receiving maintenance dialysis after the onset of the COVID-19 pandemic in Ontario, Canada

Background — The impact of the COVID-19 pandemic on clinical outcomes and healthcare utilization in patients receiving maintenance dialysis is unclear.

Objective — To compare the rates of clinical outcomes and healthcare utilization in patients receiving maintenance dialysis (in-center and home modalities) before and during the COVID-19 pandemic.

Design — Population-based, repeated cross-sectional study.

Setting — Linked administrative healthcare databases from Ontario, Canada.

Patients — Adults receiving maintenance dialysis from March 15, 2017, to March 14, 2020 (pre-COVID-19 pandemic period) and from March 15, 2020, to March 14, 2023 (COVID-19 pandemic period).

Measurements — Our primary outcome was all-cause mortality. Our secondary outcomes included non-COVID-19-related mortality, all-cause hospitalizations (excluding elective surgeries), emergency room visits, intensive care unit admissions, and hospital admissions with mechanical ventilation. We also examined cardiovascular-related hospitalizations, kidney-related outcomes, and ambulatory visits.

Methods — We used Poisson generalized estimating equations to model pre-COVID outcome trends and used these to predict post-COVID outcomes and to estimate the relative change (i.e., the ratio of the observed to the expected rate).

Results — In 31 900 individuals receiving maintenance dialysis during the study period, the crude incidence rate (per 1000 person-years) of all-cause mortality was 165.0 in the pre-COVID-19 period, compared to 173.2 during the first year of the pandemic and 171.7 during the first 36 months of the pandemic. After adjustment, there was a statistically significant increase in all-cause mortality in 14 out of the 36 months of the COVID-19 period compared to the pre-COVID-19 period, with 494 recorded COVID-19-related deaths. However, when examining the overall all-cause mortality across the months, the adjusted relative rate (aRR) comparing the observed to expected all-cause mortality rate was not statistically significant in the first year of the pandemic (1.08, 95% CI: 1.00, 1.16) and the first 36 months of the pandemic (1.08, 95% CI: 0.99, 1.18) compared to the pre-pandemic period. The crude incidence rate of non-COVID-19-related mortality was 165.0 in the pre-COVID-19 period, compared to 163.3 during the first year of the pandemic and 157.7 during the first 36 months. After adjustment, there was no substantial change in the rate of non-COVID-19-related deaths in the first year of the pandemic (aRR 1.01, 95% CI: 0.94, 1.09), but there was a substantial decrease in all-cause hospitalization, with an aRR of 0.92 (95% CI: 0.88, 0.97), and a substantial decrease in emergency room visits and intensive care unit admissions; findings were consistent 36 months into the pandemic.

Limitations — External generalizability to other jurisdictions may be limited, with each region experiencing different COVID-19 rates and implementing different mitigation strategies.

Conclusions — In the maintenance dialysis population, all-cause mortality was significantly higher during several months of the pandemic; however, the overall rate of all-cause mortality was not substantially higher than expected in the first 36 months of the COVID-19 pandemic. There was no substantial increase in non-COVID-19-related mortality despite a substantial decrease in acute healthcare utilization. Ongoing monitoring of the dialysis population will offer further insights into the long-term effects of the pandemic.