title: Geographic variation and neighborhood factors are associated with low rates of pre-end-stage renal disease nephrology care.
abstract: Geographic variation of pre-end-stage renal disease (pre-ESRD) nephrology care has not been studied across the United States. Here we sought to identify geographic differences in pre-ESRD care, assess for county-level geographic and sociodemographic risk factors, and correlate with patient outcomes using facility-level mortality. Patients from 5387 dialysis facilities across the United States from 2007 to 2010 were included from the Dialysis Facility Report. Marginal generalized estimating equations were used for modeling with geographic cluster analysis to detect clusters of facilities with low rates of pre-ESRD care. On average, 67% of patients received pre-ESRD care in the United States but with significant variability across regions ranging from 3 to 99%. Five geographic clusters of facilities with low rates of pre-ESRD care were the metropolitan areas of San Francisco, Los Angeles, Chicago, Miami, and Baltimore, along with Southern states along the Mississippi River. Dialysis facilities with the lowest rates of pre-ESRD care were more likely to be located in urban counties with high African-American populations and low educational attainment. A 10% higher proportion of patients receiving pre-ESRD care was associated with 1.3% lower patient mortality as reflected by facility-level mortality. Thus, geographic and sociodemographic factors can be used to design quality improvement initiatives to increase access to nephrology care nationwide and improve patient outcomes.
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
authors.forename: Hua
authors.initials: H
authors.lastname: Hao
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia, USA.
authors.forename: Brendan P
authors.initials: BP
authors.lastname: Lovasik
authors.affiliation: Renal Division, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.|Emory Transplant Center, Atlanta, Georgia, USA.
authors.forename: Stephen O
authors.initials: SO
authors.lastname: Pastan
authors.affiliation: Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia, USA.
authors.forename: Howard H
authors.initials: HH
authors.lastname: Chang
authors.affiliation: Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA.|Department of Global Health, Rollins School of Public Health, Atlanta, Georgia, USA.
authors.forename: Ritam
authors.initials: R
authors.lastname: Chowdhury
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.|Emory Transplant Center, Atlanta, Georgia, USA.|Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Patzer
mesh_terms: D001741:Black or African American; D016000:Cluster Analysis; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility / Q000639:trends*; D054625:Healthcare Disparities / Q000208:ethnology / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009398:Nephrology / Q000639:trends*; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000208:ethnology / Q000401:mortality / Q000628:therapy*; D012111:Residence Characteristics; D012307:Risk Factors; D019035:Rural Health Services / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D019037:Urban Health Services / Q000639:trends