title: Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.
abstract: We sought to determine whether late referral to a nephrologist in patients with chronic renal failure influences the adequacy of vascular access for hemodialysis. We analyzed data describing all health care encounters for all Medicare and Medicaid patients with end-stage renal failure in New Jersey between January 1991 and June 1996. Patients were required to have been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. In the resulting cohort of 2,398 incident hemodialysis patients, 35% had their first nephrologist consultation < or =90 days prior to initiation of dialysis. After controlling for demographic characteristics, socio-economic status and underlying renal disease, we found that patients who were referred to a nephrologist >90 days prior to onset of hemodialysis were 38% more likely to have undergone predialysis vascular access surgery than those who were referred to a nephrologist < or =90 days before dialysis [OR: 1.38; 95% CI (1.15; 1.64)]. Similarly, patients referred late were 42% more likely to require central venous access for hemodialysis compared to those seen by a nephrologist early [OR: 1.42; 95% CI (1.17; 1.71)]. Inadequate development of vascular access for renal replacement therapy in patients with late nephrologist referral unnecessarily contributes to the burden of disease experienced by this vulnerable patient population.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA. javorn@rics.bwh.harvard.edu
authors.forename: Jerry
authors.initials: J
authors.lastname: Avorn
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
authors.forename: Rhonda L
authors.initials: RL
authors.lastname: Bohn
authors.forename: Raisa
authors.initials: R
authors.lastname: Levin
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Glynn
authors.forename: Elliot
authors.initials: E
authors.lastname: Levy
authors.forename: William
authors.initials: W
authors.lastname: Owen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data; D001807:Blood Vessel Prosthesis / Q000706:statistics & numerical data; D002405:Catheterization, Central Venous / Q000706:statistics & numerical data; D015331:Cohort Studies; D017281:Cost of Illness; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000191:economics / Q000628:therapy*; D008297:Male; D008484:Medicaid / Q000592:standards; D006278:Medicare / Q000592:standards; D008875:Middle Aged; D009398:Nephrology / Q000592:standards*; D009515:New Jersey; D012017:Referral and Consultation / Q000592:standards*; D006435:Renal Dialysis / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome