title: Nephrologist care and mortality in patients with chronic renal insufficiency.
abstract: BACKGROUND
  For patients with chronic renal insufficiency, rates of referral to nephrologists are highly variable, and little is known about the effect of such consultation on clinical outcomes. We sought to determine whether early or frequent access to nephrologist care prior to the initiation of dialysis was associated with a difference in mortality rates in the first year after dialysis began.
  
  
  METHODS
  We identified all patients in the New Jersey Medicaid and Medicare programs who began maintenance dialysis during a 6-year period and who had been diagnosed with renal disease more than 12 months prior to dialysis. Use of nephrologist services was documented during this 1-year period, along with other clinical and sociodemographic variables. The outcome measure of our analysis was mortality in the first year after initiation of dialysis.
  
  
  RESULTS
  From multivariate analyses, we found that patients who did not see a nephrologist until 90 days or less before initiation of dialysis had a 37% higher likelihood of death in the first year of dialysis compared with patients with earlier referral (95% confidence interval, 1.22-1.52; P<.001). Similarly, those who saw a nephrologist on fewer than 5 occasions in the year prior to dialysis had a 15% higher mortality rate in the first year of dialysis compared with those who had had 5 or more nephrologist visits (95% confidence interval, 1.03-1.28; P =.01).
  
  
  CONCLUSIONS
  For patients with long-standing renal disease, earlier consultation with a nephrologist and more frequent specialist encounters is associated with lower mortality in the first year of dialysis. These findings need to be confirmed in younger and less indigent patients as well.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Jerry
authors.initials: J
authors.lastname: Avorn
authors.forename: Rhonda L
authors.initials: RL
authors.lastname: Bohn
authors.forename: Elliott
authors.initials: E
authors.lastname: Levy
authors.forename: Raisa
authors.initials: R
authors.lastname: Levin
authors.forename: William F
authors.initials: WF
authors.lastname: Owen
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Glynn
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D009515:New Jersey / Q000453:epidemiology; D011237:Predictive Value of Tests; D006435:Renal Dialysis; D016019:Survival Analysis; D013997:Time Factors