title: The associations between race and geographic area and quality-of-care indicators in patients approaching ESRD.
abstract: OBJECTIVE
  Pre-ESRD care is an important predictor of outcomes in patients undergoing long-term dialysis. This study examined the extent of variation in receiving pre-ESRD care and black-white disparities across urban and rural counties.
  
  
  METHODS
  Participants were 404,622 non-Hispanic white and black patients aged >18 years who began dialysis between 2005 and 2010 and resided in 3076 counties from the U.S. Renal Data System. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties. Pre-ESRD care indicators included receipt of nephrologist care at least 6 or 12 months before ESRD, dietitian care, use of arteriovenous fistula at first outpatient dialysis session, and use of erythropoiesis-stimulating agents (ESAs) in patients with hemoglobin level < 10 g/dl.
  
  
  RESULTS
  Large metropolitan and rural counties had lower percentages of patients who received pre-ESRD nephrologist care (25.7% and 26.9% for nephrologist care > 12 months), compared with the higher percentage in medium/small metropolitan counties (31.6%; both P<0.001). For both races, nonmetropolitan patients had poorer access to dietitian care and lower ESA use than metropolitan patients. Consistently in all four geographic areas, black patients received less care than their white counterparts. The unadjusted odds ratios of black versus white patients in receiving nephrologist care for >12 months before ESRD were 0.66 (95% confidence interval [CI], 0.61-0.72) in large metropolitan counties and 0.79 (95% CI, 0.69-0.90) in rural counties. The patterns remained, albeit attenuated, after adjustment for patient factors.
  
  
  CONCLUSIONS
  The receipt of pre-ESRD care, with blacks receiving less care, varies among geographic areas defined by urban/rural characteristics.
authors.affiliation: Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA 22908, USA. guofen.yan@virginia.edu
authors.forename: Guofen
authors.initials: G
authors.lastname: Yan
authors.forename: Alfred K
authors.initials: AK
authors.lastname: Cheung
authors.forename: Jennie Z
authors.initials: JZ
authors.lastname: Ma
authors.forename: Alison J
authors.initials: AJ
authors.lastname: Yu
authors.forename: Tom
authors.initials: T
authors.lastname: Greene
authors.forename: M Norman
authors.initials: MN
authors.lastname: Oliver
authors.forename: Wei
authors.initials: W
authors.lastname: Yu
authors.forename: Keith C
authors.initials: KC
authors.lastname: Norris
mesh_terms: D000368:Aged; D044383:Black People / Q000706:statistics & numerical data*; D016208:Databases, Factual / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000592:standards* / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000208:ethnology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000592:standards / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data; D044465:White People / Q000706:statistics & numerical data*; D001741:Black or African American