title: Interstate Variation in Receipt of Nephrologist Care in US Patients Approaching ESRD: Race, Age, and State Characteristics.
abstract: OBJECTIVE
  Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD.
  
  
  METHODS
  This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care (≥12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years).
  
  
  RESULTS
  The average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P<0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation.
  
  
  CONCLUSIONS
  Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.
authors.affiliation: Departments of Public Health Sciences and guofen.yan@virginia.edu.
authors.forename: Guofen
authors.initials: G
authors.lastname: Yan
authors.affiliation: Divisions of Nephrology and Hypertension and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah;
authors.forename: Alfred K
authors.initials: AK
authors.lastname: Cheung
authors.affiliation: Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah;
authors.forename: Tom
authors.initials: T
authors.lastname: Greene
authors.affiliation: Keck School of Medicine, University of Southern California, Los Angeles, California; and.
authors.forename: Alison J
authors.initials: AJ
authors.lastname: Yu
authors.affiliation: Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia;
authors.forename: M Norman
authors.initials: MN
authors.lastname: Oliver
authors.affiliation: Departments of Public Health Sciences and.
authors.forename: Wei
authors.initials: W
authors.lastname: Yu
authors.affiliation: Departments of Public Health Sciences and.
authors.forename: Jennie Z
authors.initials: JZ
authors.lastname: Ma
authors.affiliation: Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, California.
authors.forename: Keith C
authors.initials: KC
authors.lastname: Norris
mesh_terms: D001741:Black or African American; D000367:Age Factors; D000368:Aged; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009398:Nephrology; D014481:United States; D044465:White People
keywords: CKD; US Renal Data System; pre-ESRD care; racial difference; state characteristics