Sociodemographic and geographic predictors of quality of care in United States patients with end-stage renal disease due to lupus nephritis

Abstract

Objective: To describe end-stage renal disease (ESRD) quality of care (receipt of pre-ESRD nephrology care, access to kidney transplantation, and placement of permanent vascular access for dialysis) in US patients with ESRD due to lupus nephritis (LN-ESRD) and to examine whether quality measures differ by patient sociodemographic characteristics or US region.

Methods: National surveillance data on patients in the US in whom treatment for LN-ESRD was initiated between July 2005 and September 2011 (n = 6,594) were analyzed. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) were determined for each quality measure, according to sociodemographic factors and US region.

Results: Overall, 71% of the patients received nephrology care prior to ESRD. Black and Hispanic patients were less likely than white patients to receive pre-ESRD care (OR 0.73 [95% CI 0.63-0.85] and OR 0.73 [95% CI 0.60-0.88], respectively) and to be placed on the kidney transplant waitlist within the first year after the start of ESRD (HR 0.78 [95% CI 0.68-0.91] and HR 0.82 [95% CI 0.68-0.98], respectively). Those with Medicaid (HR 0.51 [95% CI 0.44-0.58]) or no insurance (HR 0.36 [95% CI 0.29-0.44]) were less likely than those with private insurance to be placed on the waitlist. Only 24% had a permanent vascular access, and placement was even less likely among the uninsured (OR 0.62 [95% CI 0.49-0.79]). ESRD quality-of-care measures varied 2-3-fold across regions of the US, with patients in the Northeast and Northwest generally having higher probabilities of adequate care.

Conclusion: LN-ESRD patients have suboptimal ESRD care, particularly with regard to placement of dialysis vascular access. Minority race/ethnicity and lack of private insurance are associated with inadequate ESRD care. Further studies are warranted to examine multilevel barriers to, and develop targeted interventions to improve delivery of, care among patients with LN-ESRD.

Figure 1

Selection of study populations for assessment of quality measures related to pre–end-stage renal disease (ESRD) nephrology care, access to transplant (informed of transplant options, time to placement on the kidney transplant waitlist), and presence of a permanent vascular access for dialysis, among US patients in whom treatment was being initiated for ESRD attributed to lupus nephritis (LN), July 1, 2005–September 30, 2011.

Figure 2

Age-, sex-, race/ethnicity-, and insurance-adjusted probability of receipt of nephrology care prior to end-stage renal disease (ESRD) (A), probability of being informed of transplant options at the start of dialysis (B), rate of placement on the kidney transplant waitlist (C), and probability of a permanent vascular access used or in place at first dialysis (D), by US region defined according to Centers for Medicare & Medicaid Services ESRD Networks, among US patients in whom treatment was being initiated for ESRD attributed to lupus nephritis, July 1, 2005–September 30, 2011.