Provider and care characteristics associated with timing of dialysis initiation.
OBJECTIVE
There is a trend in the United States to maintenance dialysis initiation at higher levels of estimated GFR. This study aimed to determine whether provider characteristics and pre-ESRD nephrology care and vascular access are independently associated with higher estimated GFR at initiation.


METHODS
This retrospective cohort study used US Renal Data System data for patients who initiated dialysis in 2006 (n=83,621) and American Medical Association Physician Master File data for provider characteristics. Patient characteristics and estimated GFR were defined, and providers at dialysis initiation were identified. Earlier dialysis initiation was defined as initiation at estimated GFR>10 ml/min per 1.73 m(2). Nephrologist density per 100 ESRD patients was calculated by Health Service Area in 2006. Associations between provider characteristics and estimated GFR were determined using logistic regression and linear regression models, accounting for provider clustering.


RESULTS
Of the cohort, 47.8% of patients initiated dialysis at estimated GFR>10 ml/min per 1.73 m(2), and 16.2% of patients initiated dialysis at estimated GFR≥15 ml/min per 1.73 m(2). Predialysis nephrologist care for 0-12 months was associated with greater odds of earlier initiation compared with no care. Patients initiating with an arteriovenous fistula or graft were more likely to initiate earlier than patients initiating with a catheter. Provider sex was not associated with timing of dialysis initiation as measured by estimated GFR. Care by providers who graduated from nondomestic medical schools was associated with greater odds of earlier initiation. Greater provider experience was associated with lower likelihood of earlier initiation.


CONCLUSIONS
This study supports the hypothesis that provider factors are associated with timing of dialysis initiation in the United States.
Primary Care Service Line, Veterans Administration Health Care System, Minneapolis, Minnesota;, †Department of Medicine, University of Minnesota, Minneapolis, Minnesota, ‡Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota.
Yelena
Y
Slinin
Haifeng
H
Guo
Suying
S
Li
Jiannong
J
Liu
Benjamin
B
Morgan
Kristine
K
Ensrud
David T
DT
Gilbertson
Allan J
AJ
Collins
Areef
A
Ishani
D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D019917:Blood Vessel Prosthesis Implantation; D002405:Catheterization, Central Venous; D002983:Clinical Competence; D018450:Disease Progression; D005260:Female; D005550:Foreign Medical Graduates; D005919:Glomerular Filtration Rate; D006801:Humans; D007668:Kidney / Q000503:physiopathology*; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult