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. 2009 May;20(5):1078-85.
doi: 10.1681/ASN.2008060624. Epub 2009 Mar 25.

Treatment center and geographic variability in pre-ESRD care associate with increased mortality

William M McClellan  1 , Haimanot Wasse, Ann C McClellan, Adam Kipp, Lance A Waller, Michael V Rocco
Affiliations

Treatment center and geographic variability in pre-ESRD care associate with increased mortality

William M McClellan et al. J Am Soc Nephrol. 2009 May.

Abstract

Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of > 30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of > or = 6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.

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Figures

Figure 1.
Figure 1.
Facility-specific SMRs by decile of pre-ESRD nephrology care. Squares represent the SMR adjusted for all patient characteristics and circles the SMR adjusted for all patient characteristics and pre-ESRD care (ESA use, incident serum albumin and hemoglobin, BMI, AVF status, and predialysis nutrition consultation).
Figure 2.
Figure 2.
Geographic clustering of low pre-ESRD nephrology care among ESRD treatment centers.
Figure 3.
Figure 3.
Map depicts the contiguous states in ESRD Networks 5, 6, 8, and 13. The map displays the natural logarithm of the estimated relative risk surface for having no predialysis nephrology care. Areas marked by “+” indicate areas significantly increased local prevalence of low pre-ESRD care centers and areas marked by “−” indicate significantly decreased local prevalence of low pre-ESRD centers.
See this image and copyright information in PMC

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