title: Late referral and modality choice in end-stage renal disease.
abstract: BACKGROUND
  We sought to determine whether late versus early referral to a nephrologist in patients with chronic kidney disease influences the initial choice of hemodialysis (HD) versus peritoneal dialysis (PD) or the likelihood of switching treatment modalities in the first six months of therapy.
  
  
  METHODS
  Using New Jersey Medicare/Medicaid claims, all patients who started RRT between January 1991 and June 1996 and were diagnosed with renal disease more than one year prior to RRT were identified. In the resulting cohort of 3014 patients, 35% had their first nephrologist consultation < or =90 days prior to initiation of dialysis.
  
  
  RESULTS
  After controlling for demographic characteristics, socioeconomic status and underlying renal disease, age, black race [Odds ratio (OR) = 0.56], race other than black or white (OR = 0.56), and socioeconomic status (OR = 0.68) influenced the choice of initial treatment modality, but timing of the referral did not. However, patients starting on PD who were referred late were 50% more likely to switch to HD than were patients who saw a nephrologist earlier [Hazard's ratio (HR) = 1.47]. In patients originally on HD, diabetic nephropathy (HR = 1.49) and black race (HR = 0.69) influenced the likelihood of switching to PD, but the timing of referral did not.
  
  
  CONCLUSIONS
  These results refute earlier findings that late referral may limit access to PD. We found that modality choice depends on factors such as age, race, or socioeconomic status, rather than on than timing of nephrologist referral. Late referral does not influence the likelihood to switch modality in patients starting on HD, but does so in patients starting on PD.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. wolfgang@post.harvard.edu
authors.forename: W C
authors.initials: WC
authors.lastname: Winkelmayer
authors.forename: R J
authors.initials: RJ
authors.lastname: Glynn
authors.forename: R
authors.initials: R
authors.lastname: Levin
authors.forename: W
authors.initials: W
authors.lastname: Owen
authors.forename: J
authors.initials: J
authors.lastname: Avorn
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005006:Ethnicity; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D016013:Likelihood Functions; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis; D012017:Referral and Consultation; D006435:Renal Dialysis; D019233:Retreatment; D012923:Social Class; D013997:Time Factors