title: Access to care and the incidence of end-stage renal disease due to diabetes.
abstract: OBJECTIVE
  Low socioeconomic status (SES) is associated with an increased risk of end-stage renal disease (ESRD) due to diabetes. Because ESRD is a preventable complication of diabetes, the association with SES may be related to limited access to treatment.
  
  
  METHODS
  In this population-based ecological study, I examined the association between the incidence of ESRD attributed to diabetes and the proportion of hospitalizations with no insurance, Medicaid, or managed care insurance; residence in a primary care provider shortage area or rural area; and rate of hospitalizations for hyperglycemic complications, by ZIP code in California in 2001-2004.
  
  
  RESULTS
  The incidence of ESRD attributed to diabetes was higher in ZIP codes with higher proportions of hospitalizations with no insurance (r = 0.45; P < 0.0001) or Medicaid (r = 0.69; P < 0.0001) and in ZIP codes with higher rates of hospitalizations for hyperglycemic complications (r = 0.27; P < 0.0001). The incidence was lower in ZIP codes with higher proportions of hospitalizations with managed care insurance (r = -0.37; P < 0.0001) and was lower in primary care provider shortage areas and rural locations. In contrast, there were only weak associations between measures of access to care and the incidence of ESRD attributed to polycystic kidney disease, a condition that is not treatable.
  
  
  CONCLUSIONS
  The incidence of ESRD attributed to diabetes is strongly associated with area-based measures of access to care, suggesting that access to treatment partly mediates the association between SES and the incidence of ESRD.
authors.affiliation: Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA. wardm1@mail.nih.gov
authors.forename: Michael M
authors.initials: MM
authors.lastname: Ward
mesh_terms: D000328:Adult; D002017:Budgets; D016208:Databases, Factual / Q000706:statistics & numerical data; D003928:Diabetic Nephropathies / Q000453:epidemiology* / Q000628:therapy; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007182:Income / Q000706:statistics & numerical data; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000628:therapy; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D011203:Poverty / Q000706:statistics & numerical data; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult