Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Mary Jo Clark, PhD, RN, Chairperson; Jane M. Georges, PhD, RN; Keith Charles Norris, PhD, MD


age, elderly, funding policies, Hemodialysis patients, nursing, pre-end stage Renal Disease care, Puerto Rico, United States


Purpose: The primary purpose of this dissertation was to examine the relationship between age and receipt of three components of pre-end stage renal disease care prior to first initiation of hemodialysis, and to explore the implications of differences in interpretation of funding policies for dialysis services in Puerto Rico and the U.S. mainland. Background: The growing burden of chronic kidney disease (CKD) is a national public health concern, particularly within the aged population. It is estimated that more than 25 million Americans are living with some level of kidney disease, with an increasing prevalence noted with increasing age (Coresh et al., 2007). Although the Center for Medicare and Medicaid Services (CMS) is the primary payer for CKD and ESRD services, differences in reimbursement policy interpretation between the U.S. mainland and Puerto Rico result in additional burdens for those served. Pre-end stage renal disease (ESRD) clinical care can improve outcomes for maintenance hemodialysis patients particularly within the elder population. Methods: Data on the extent of pre-ESRD care by age were derived from the U.S. Renal Disease Data System for all patients started on dialysis from 2005 to 2010. Study variables included: (a) receipt of nephrology care 12 months prior to starting dialysis, (b) receipt of dietitian care at any time prior to starting dialysis, and (c) use of AVF at first dialysis. Data for the policy analysis was derived from CMS documents and interviews with stakeholders and regulatory agencies. Results: Less than 2% of MHD patients received all three pre-ESRD care elements, and 63.3% received none of the three elements of care. The mean number of pre-ESRD care elements received by the oldest group (≥80 years) did not differ from the youngest group (≥55 years), but was less than the 55-66 and 67-79 years groups. The policy analysis revealed regional variations in the interpretation of the coordination of ESRD benefits between the Territory of Puerto Rico and the national health system. Implications: Major efforts are needed to ensure comprehensive pre-ESRD care for all patients with chronic kidney disease as well as a harmonizing of ESRD coordination of benefits for dialysis patients.

Document Type

Dissertation: Open Access



Included in

Nursing Commons