{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,18]],"date-time":"2025-11-18T16:04:16Z","timestamp":1763481856912,"version":"3.45.0"},"reference-count":4,"publisher":"American Medical Association (AMA)","issue":"11","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Uninsured patients who initiate hemodialysis (HD) typically cannot be placed in outpatient HD centers until their insurance applications are processed. Allowing these patients temporary access to an inpatient HD unit as outpatients could shorten their hospital length of stay (LOS).<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate the association of hospital LOS with a first-in-state model in which an inpatient HD unit received regulatory program flex approval to provide temporary, transitional outpatient access to uninsured patients.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This quasi-experimental, pre-post quality improvement study was conducted at 1 intervention hospital and 2 control hospitals within the safety net of the Los Angeles County Department of Health Services among uninsured inpatients who newly initiated HD from January 1, 2016, through December 31, 2024.<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n Transitional outpatient HD access to an inpatient unit was implemented in February of 2020 at the Los Angeles General Medical Center (LA General). Control hospitals began to use their emergency departments for outpatient HD access during the intervention period.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome measure was the difference in LOS before vs after transitional HD implementation. Secondary outcomes included all-cause 30-day readmission and mortality rates.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Overall, 951 patients were included in this study. In the preintervention period, LA General treated 200 uninsured inpatients newly initiating HD (mean [SD] age, 52.0 [11.7] years; 130 men [65.0%]) vs 241 patients (mean [SD] age, 52.9 [11.1] years; 171 men [71.0%]) in the postintervention period. The mean (SD) LOS at LA General was significantly shorter after vs before the intervention (7.6 [6.6] vs 13.0 [17.5] days;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001). At control hospitals, 234 patients (mean [SD] age, 52.4 [13.6] years; 164 men [70.1%]) were treated in the preintervention period, and 276 patients (mean [SD] age, 52.7 [12.5] years; 209 men [75.7%]) were treated in the postintervention period. The mean (SD) LOS at control hospitals was significantly shorter after vs before the intervention (9.1 [9.4] vs 12.5 [15.3] days;\n P<\/jats:italic>\n \u2009=\u2009.002). Difference-in-difference analysis did not demonstrate a reduction in LOS at LA General vs control hospitals (\u22122.0 days;\n P<\/jats:italic>\n \u2009=\u2009.23). However, run charts demonstrated immediate, sustained reductions in LOS at LA General but variations in LOS after the intervention at the control hospitals, such that the parallel trends assumption for difference-in-difference validity was likely not met.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this quality improvement study, regulatory approval of an inpatient HD unit to provide transitional, outpatient services to uninsured patients newly initiating HD was associated with a significantly reduced LOS. These results suggest that this model could be a viable solution for other hospitals facing similar difficulties with expeditious discharge planning for uninsured patients undergoing HD.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.44295","type":"journal-article","created":{"date-parts":[[2025,11,18]],"date-time":"2025-11-18T16:00:16Z","timestamp":1763481616000},"page":"e2544295","source":"Crossref","is-referenced-by-count":0,"title":["Provision of Temporary Access to Inpatient Hemodialysis to Uninsured Patients Initiating Hemodialysis"],"prefix":"10.1001","volume":"8","author":[{"given":"Josh","family":"Banerjee","sequence":"first","affiliation":[{"name":"Hospital Administration, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hugh","family":"Gordon","sequence":"additional","affiliation":[{"name":"Hospital Administration, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Victoria E.","family":"Walsh","sequence":"additional","affiliation":[{"name":"Department of Regulatory Affairs, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jasmine S.","family":"Espiritu","sequence":"additional","affiliation":[{"name":"Department of Regulatory Affairs, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Catherine","family":"Canamar","sequence":"additional","affiliation":[{"name":"Department of Quality, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Soodtida","family":"Tangprahaphorn","sequence":"additional","affiliation":[{"name":"Department of Quality, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hannah H.","family":"Oh","sequence":"additional","affiliation":[{"name":"Division of Hemodialysis, Department of Nursing, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jacklyn P.","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Division of Hemodialysis, Department of Nursing, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tammy","family":"Yun","sequence":"additional","affiliation":[{"name":"Division of Hemodialysis, Department of Nursing, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Young Shin","family":"Seo","sequence":"additional","affiliation":[{"name":"Division of Hemodialysis, Department of Nursing, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Young","family":"Song","sequence":"additional","affiliation":[{"name":"Division of Hemodialysis, Department of Nursing, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mark","family":"Redulla","sequence":"additional","affiliation":[{"name":"Division of Hemodialysis, Department of Nursing, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Melissa","family":"Alvarez","sequence":"additional","affiliation":[{"name":"Department of Medicine, Keck School of Medicine at the University of Southern California, Los Angeles"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arshia","family":"Ghaffari","sequence":"additional","affiliation":[{"name":"Department of Medicine, Keck School of Medicine at the University of Southern California, Los Angeles"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Douglass","family":"Hutcheon","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Department of Medicine, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jan","family":"Shoenberger","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Varnal","sequence":"additional","affiliation":[{"name":"Patient and Family Advisory Council, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nancy","family":"Blake","sequence":"additional","affiliation":[{"name":"Hospital Administration, Los Angeles General Medical Center, Los Angeles, California"},{"name":"School of Nursing, University of California, Los Angeles"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"suffix":"Jr","given":"Charles E.","family":"Coffey","sequence":"additional","affiliation":[{"name":"Hospital Administration, Los Angeles General Medical Center, Los Angeles, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brad","family":"Spellberg","sequence":"additional","affiliation":[{"name":"Hospital Administration, Los Angeles General Medical Center, Los Angeles, California"},{"name":"Department of Medicine, Keck School of Medicine at the University of Southern California, Los Angeles"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","published-online":{"date-parts":[[2025,11,18]]},"reference":[{"issue":"1","key":"zoi251197r1","doi-asserted-by":"publisher","first-page":"c19","DOI":"10.1159\/000245066","article-title":"Inpatient hemodialysis initiation: reasons, risk factors and outcomes.","volume":"114","author":"Crews","year":"2010","journal-title":"Nephron Clin Pract"},{"issue":"2","key":"zoi251197r3","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1056\/NEJMsa2206117","article-title":"The safety of inpatient health care.","volume":"388","author":"Bates","year":"2023","journal-title":"N Engl J Med"},{"issue":"5","key":"zoi251197r4","doi-asserted-by":"publisher","first-page":"628","DOI":"10.1097\/EDE.0000000000001755","article-title":"Advances in difference-in-differences methods for policy evaluation research.","volume":"35","author":"Wang","year":"2024","journal-title":"Epidemiology"},{"key":"zoi251197r2","volume-title":"Measuring Quality Improvement in Healthcare","author":"Carey","year":"2001"}],"container-title":["JAMA Network 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