Health Care-Related Transportation Insecurity and Associated Adverse Health Outcomes in Adults with Kidney Disease: A National Cross-Sectional Study

BACKGROUND: Health care-related transportation insecurity, defined as delayed medical care due to lack of transportation, is an increasingly recognized social risk factor that impedes access to care. While its impact has been described among people receiving dialysis, its prevalence and clinical significance across the kidney disease continuum remain poorly understood. We examined the prevalence of transportation insecurity among U.S. adults with self-reported kidney disease and its associations with health status, work productivity, acute health care utilization, and mortality. METHODS: In this national cross-sectional study of non-institutionalized U.S. adults >18 years with self-reported kidney disease in the National Health Interview Survey (2014 to 2018), we used complex survey weighting to obtain the national prevalence of health care-related transportation insecurity and examine its associations with emergency department visits, hospitalizations, all-cause mortality, self-reported health status and work productivity, adjusting for sociodemographic and clinical characteristics. RESULTS: Overall, 3,824 respondents (representing 5.0 million U.S. adults) reported kidney disease, of whom 8% (n = 326; representing 384,882 individuals) experienced health care-related transportation insecurity. It was associated with lower income, nonprivate or no insurance, and work limitations. Compared with those without health care-related transportation insecurity, affected individuals had higher risk of emergency department use (aOR 1.8; 95% CI 1.3 to 2.5), hospitalizations (aOR 1.6; 95% CI 1.2 to 2.3), and was independently associated with all-cause mortality (aHR 1.8; 95% CI 1.5 to 2.1). Health care-related transportation insecurity was also associated with higher odds of daily depressive symptoms (aOR 2.2; 95% CI 1.4 to 3.6) and work limitations (aOR 2.5; 95% CI 1.7 to 3.7). CONCLUSIONS: Health care-related transportation insecurity affects a substantial proportion of U.S. adults with kidney disease and is associated with worse health status, reduced work productivity, greater health care utilization, and higher all-cause mortality. These findings support efforts to address transportation barriers and improve access to care across the kidney disease continuum.