Treatment Center and Geographic Variability in Pre-ESRD Care Associate with Increased Mortality

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 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.

Geographic Variation in HMG-CoA Reductase Inhibitor Use in Dialysis Patients

“…Our results extend an emerging literature identifying regional differences in the care of chronic dialysis patients. Specialty and procedural care, such as hemodialysis catheter use, 42,43 access to kidney transplantation, 44 arteriovenous fistula creation, 45 and even access to pre-ESRD care 46 have all been recently found to vary geographically. Our study extends this realm of inquiry into the provision of readily-available medications, in this case, statins.…”

Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD

“…The consequences of CKD are severe, including progression to ESRD and premature development of cardiovascular diseases and death (2)(3)(4)(5)(6)(7). Although no randomized trials have been performed, .20 years of accumulating evidence has suggested that early nephrologist care is associated with slower CKD progression and lower rates of adverse outcomes (8)(9)(10)(11)(12)(13)(14)(15)(16). Despite practice guidelines recommending that patients in CKD stages 4-5 should be under nephrologist care (6,17), late nephrologist care is still common (18).…”

“…Although the receipt of nephrologist care is influenced by individual as well as contextual factors such as those related to residence, prior studies have mostly examined individual factors (12,(19)(20)(21), or the few studies that examined contextual factors have generally examined them separately (22)(23)(24) or were limited to certain regional areas (15,25). An important knowledge gap exists regarding broad regional (e.g., state-level) differences in the utilization of nephrologist care among patients with CKD stages 4-5.…”

Regional Variation in the Incidence of Dialysis-Requiring AKI in the United States

“…It adds to the growing literature on the importance of geographic variation in kidney disease epidemiology (17,28,29). Additional research is needed to clarify whether geographic differences are because of AKI risk factors, practice pattern differences, or some other cause to develop potential preventative interventions.…”