title: The timing of specialist evaluation in chronic kidney disease and mortality.
abstract: BACKGROUND
  Care for chronic renal failure involves management of complications and preparation for possible dialysis. Patients often are not evaluated by nephrologists in a timely manner.
  
  
  OBJECTIVE
  To identify factors associated with late evaluation by a nephrologist and to assess whether late evaluation is associated with worse survival once patients develop end-stage renal disease (ESRD).
  
  
  METHODS
  National prospective cohort study.
  
  
  METHODS
  81 dialysis facilities throughout the United States.
  
  
  METHODS
  828 patients with new-onset ESRD.
  
  
  METHODS
  Time from first evaluation by a nephrologist to initiation of dialysis, classified as late (<4 months), intermediate (4 to 12 months), or early (>12 months); rate of death, from initiation of dialysis to an average of 2.2 years of follow-up; and demographic, clinical, and laboratory characteristics.
  
  
  RESULTS
  After adjustment for potential confounders, late evaluation was more common among black men than white men (44.8% vs. 24.5%; P < 0.05), uninsured patients than insured patients (56.7% vs. 29.0%; P < 0.05) and patients with severe comorbid disease than those with mild comorbid disease (35.0% vs. 23.0%; P < 0.05). Compared with patients who had early evaluation, the risk for death was greater among patients evaluated late and was graded (hazard ratio, 1.3 [95% CI, 0.87 to 2.06] for patients with intermediate evaluation and 1.8 [CI, 1.21 to 2.61] for those with late evaluation) after adjustment for dialysis method, demographic characteristics, and socioeconomic status in Cox proportional hazards regression analysis. After additional adjustment for such factors as the presence and severity of comorbid conditions, the association remained graded (hazard ratio, 1.2 [CI, 0.73 to 1.82] for patients evaluated at an intermediate point and 1.6 [CI, 1.04 to 2.39] for those evaluated late).
  
  
  CONCLUSIONS
  Late evaluation of patients with chronic renal failure by a nephrologist is associated with greater burden and severity of comorbid disease, black ethnicity, lack of health insurance, and shorter duration of survival.
authors.affiliation: Robert Wood Johnson Clinical Scholars Program and Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205-2223, USA.
authors.forename: Kraig S
authors.initials: KS
authors.lastname: Kinchen
authors.forename: John
authors.initials: J
authors.lastname: Sadler
authors.forename: Nancy
authors.initials: N
authors.lastname: Fink
authors.forename: Ronald
authors.initials: R
authors.lastname: Brookmeyer
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Klag
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Levey
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
mesh_terms: D001741:Black or African American; D000368:Aged; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis* / Q000208:ethnology / Q000401:mortality*; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D009398:Nephrology; D010530:Peritoneal Dialysis; D011446:Prospective Studies; D012017:Referral and Consultation; D006435:Renal Dialysis; D012680:Sensitivity and Specificity; D012959:Socioeconomic Factors; D015996:Survival Rate; D013997:Time Factors; D014481:United States / Q000453:epidemiology