title: Survival benefit of nephrologic care in patients with diabetes mellitus and chronic kidney disease.
abstract: BACKGROUND
  The association of nephrologic care and survival in patients with diabetes mellitus and chronic kidney disease is unknown.
  
  
  METHODS
  Using data from 1997 to 2000, we conducted a retrospective cohort study of Veterans Health Administration clinic users having diabetes mellitus and stage 3 or 4 chronic kidney disease. The baseline period was 12 months and median follow-up was 19.3 months. Degree of consistency of visits to a nephrologist, defined as the number of calendar quarters in which there was 1 visit or more (range, 0-4 quarters), and covariates were calculated from the baseline period. The outcome measure was dialysis-free death.
  
  
  RESULTS
  Of 39,031 patients, 70.0%, 22.4%, and 7.6% had early stage 3, late stage 3, and stage 4 chronic kidney disease, respectively, and 3.1%, 9.5%, and 28.2%, respectively, visited a nephrologist. Dialysis-free mortality rates were 9.6, 14.1, and 19.4, respectively, per 100 person-years. More calendar quarters with visits to a nephrologist were associated with lower mortality: adjusted hazard ratios were 0.80 (95% confidence interval, 0.67-0.97), 0.68 (95% confidence interval, 0.55-0.86), and 0.45 (95% confidence interval, 0.32-0.63), respectively, when the groups having 2, 3, and 4 visits were compared with those who had no visits. One visit only was not associated with a difference in mortality when compared with no visits (adjusted hazard ratio,1.02; 95% confidence interval, 0.89-1.16).
  
  
  CONCLUSIONS
  The consistency of outpatient nephrologic care was independently associated in a graded fashion with lower risk of deaths in patients with diabetes and moderately severe to severe chronic kidney disease. However, only a minority of patients had any visits to a nephrologist.
authors.affiliation: Department of Veterans Affairs Center for Healthcare Knowledge Management, Department of Veterans Affairs, New Jersey Health Care System, East Orange, NJ 07018, USA. chin-lin.tseng@va.gov
authors.forename: Chin-Lin
authors.initials: CL
authors.lastname: Tseng
authors.forename: Elizabeth F O
authors.initials: EF
authors.lastname: Kern
authors.forename: Donald R
authors.initials: DR
authors.lastname: Miller
authors.forename: Anjali
authors.initials: A
authors.lastname: Tiwari
authors.forename: Miriam
authors.initials: M
authors.lastname: Maney
authors.forename: Mangala
authors.initials: M
authors.lastname: Rajan
authors.forename: Leonard
authors.initials: L
authors.lastname: Pogach
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000401:mortality* / Q000628:therapy*; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality* / Q000628:therapy*; D008297:Male; D009398:Nephrology; D012017:Referral and Consultation; D012189:Retrospective Studies; D015996:Survival Rate