title: Treatment center and geographic variability in pre-ESRD care associate with increased mortality.
abstract: Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of > 30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of > or = 6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.
authors.affiliation: Emory University School of Medicine, Renal Division, Rollins School of Public Health, Room 476, 1518 Clifton Road, Atlanta, GA 30322, USA. wmcclel@sph.emory.edu
authors.forename: William M
authors.initials: WM
authors.lastname: McClellan
authors.forename: Haimanot
authors.initials: H
authors.lastname: Wasse
authors.forename: Ann C
authors.initials: AC
authors.lastname: McClellan
authors.forename: Adam
authors.initials: A
authors.lastname: Kipp
authors.forename: Lance A
authors.initials: LA
authors.lastname: Waller
authors.forename: Michael V
authors.initials: MV
authors.lastname: Rocco