title: Prevalence of pre-end-stage renal disease care and associated outcomes among urban, micropolitan, and rural dialysis patients.
abstract: OBJECTIVE
  Pre-end-stage renal disease (ESRD) care is associated with improved outcomes among patients receiving dialysis. It is unknown what proportion of US micropolitan and rural dialysis patients receive pre-ESRD care and benefit from such care when compared to urban.
  
  
  METHODS
  A retrospective cohort study was performed using data from the US Renal Data System. Patients ≥18 years old who initiated dialysis in 2006 and 2007 were classified as rural, micropolitan or urban and the prevalence of pre-ESRD care (early nephrology care >6 months, permanent vascular access, -dietary education) was determined using the medical evidence report. The association of pre-ESRD care with dialysis mortality and transplantation was assessed using Cox regression with stratification for geographic residence.
  
  
  RESULTS
  Of 204,463 dialysis patients, 80% were urban, 10.2% were micropolitan and 9.8% were rural. Overall attainment of pre-ESRD care was poor. After adjustment, there were no significant geographic differences in attainment of early nephrology care or permanent dialysis access. Receiving care reduced all-cause mortality and increased the likelihood of transplantation to a similar degree regardless of geographic residence. Both micropolitan and rural patients received less dietary education (relative risk = 0.80, 95% CI = 0.76-0.84 and relative risk = 0.85, 95% CI = 0.80-0.89, respectively).
  
  
  CONCLUSIONS
  Among patients who receive dialysis, the prevalence of early nephrology care and permanent dialysis access is poor and does not vary by geographic residence. Micropolitan and rural patients receive less dietary education despite an observed mortality benefit, suggesting that barriers may exist to quality dietary care in more remote locations.
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
authors.forename: Saugar
authors.initials: S
authors.lastname: Maripuri
authors.forename: T Alp
authors.initials: TA
authors.lastname: Ikizler
authors.forename: Kerri L
authors.initials: KL
authors.lastname: Cavanaugh
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data; D015331:Cohort Studies; D004035:Diet Therapy / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000401:mortality / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D019035:Rural Health Services / Q000706:statistics & numerical data*; D014481:United States; D019037:Urban Health Services / Q000706:statistics & numerical data*; D062666:Vascular Access Devices / Q000706:statistics & numerical data
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