SummaryAdequate pre-dialysis care reduces mortality among end-stage renal disease (ESRD) patients. We tested the hypothesis that individuals with ESRD due to sickle cell disease (SCD-ESRD) receiving pre-ESRD care have lower mortality compared to individuals without pre-ESRD care. We examined the association between mortality and pre-ESRD care in incident SCD-ESRD patients who started haemodialysis between 1 June, 2005 and 31 May, 2009 using data provided by the Centers for Medicare and Medicaid Services (CMS). SCD-ESRD was reported for 410 (0Á1%) of 442 017 patients. One year after starting dialysis, 108 (26Á3%) patients with incident ESRD attributed to SCD died; the hazard ratio (HR) for mortality among patients with SCD-ESRD compared to those without SCD as the primary cause of renal failure was 2Á80 (95% confidence interval [CI] 2Á31-3Á38). Patients with SCD-ESRD receiving pre-dialysis nephrology care had a lower death rate than those with SCD-ESRD who did not receive predialysis nephrology care (HR = 0Á67, 95% CI 0Á45-0Á99). The one-year mortality rate following an ESRD diagnosis was almost three times higher in individuals with SCD when compared to those without SCD but with ESRD and could be attenuated by pre-dialysis nephrology care.

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 Ͼ30,000 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 ϭ 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 Ն6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.

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Purpose: To estimate travel distance and time for US hemodialysis patients and to compare travel of rural versus urban patients.Methods: Dialysis patient residences were estimated from ZIP code-level patient counts as of February 2011 allocated within the ZIP code proportional to census tract-level population, obtained from the 2010 US Census. Dialysis facility addresses were obtained from Medicare public-use files. Patients were assigned to an "original" and "replacement" facility, assuming patients used the facility closest to home and would select the next closest facility as a replacement, if a replacement facility was required. Driving distances and times were calculated between patient residences and facility locations using GIS software. Findings:The mean one-way driving distance to the original facility was 7.9 miles; for rural patients average distances were 2.5 times farther than for urban patients (15.9 vs 6.2 miles). Mean driving distance to a replacement facility was 10.6 miles, with rural patients traveling on average 4 times farther than urban patients to a replacement facility (28.8 vs 6.8 miles). Conclusion:Rural patients travel much longer distances for dialysis than urban patients. Accessing alternative facilities, if required, would greatly increase rural patient travel, while having little impact on urban patients. Increased travel could have clinical implications as longer travel is associated with increased mortality and decreased quality of life.