title: Predialysis nephrology care of older patients approaching end-stage renal disease.
abstract: BACKGROUND
  Little is known about trends in the timing of first nephrology consultation and associated outcomes among older patients initiating dialysis.
  
  
  METHODS
  Data from patients aged 67 years or older who initiated dialysis in the United States between January 1, 1996, and December 31, 2006, were stratified by timing of the earliest identifiable nephrology visit. Trends of earlier nephrology consultation were formally examined in light of concurrently changing case mix and juxtaposed with trends in 1-year mortality rates after initiation of dialysis.
  
  
  RESULTS
  Among 323,977 older patients initiating dialysis, the proportion of patients receiving nephrology care less than 3 months before initiation of dialysis decreased from 49.6% (in 1996) to 34.7% (in 2006). Patients initiated dialysis with increasingly preserved kidney function, from a mean estimated glomerular filtration rate of 8 mL/min/1.73 m(2) in 1996 to 12 mL/min/1.73 m(2) in 2006. Patients were less anemic in later years, which was partly attributable to increased use of erythropoiesis-stimulating agents, and fewer used peritoneal dialysis as the initial modality. During the same period, crude 1-year mortality rates remained unchanged (annual change in mortality rate, +0.2%; 95% confidence interval, 0% to +0.4%). Adjustment for changes in demographic and comorbidity patterns yielded estimated annual reductions in 1-year mortality rates of 0.9% (95% confidence interval, 0.7% to 1.1%), which were explained only partly by concurrent trends toward earlier nephrology consultation (annual mortality reduction after accounting for timing of nephrology care was attenuated to 0.4% [0.2% to 0.6%]).
  
  
  CONCLUSIONS
  Despite significant trends toward earlier use of nephrology consultation among older patients approaching maintenance dialysis, we observed no material improvement in 1-year survival rates after dialysis initiation during the same time period.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA. wcw1@stanford.edu
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Chertow
authors.forename: Manjula Kurella
authors.initials: MK
authors.lastname: Tamura
mesh_terms: D000368:Aged; D018450:Disease Progression; D005260:Female; D006801:Humans; D007388:Internal Medicine; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D009398:Nephrology; D016012:Poisson Distribution; D012017:Referral and Consultation; D006435:Renal Dialysis; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors; D014481:United States / Q000453:epidemiology