title: Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA.
abstract: BACKGROUND
  Longer nephrology care before end-stage renal disease (ESRD) has been linked with better outcomes.
  
  
  METHODS
  We investigated whether longer pre-end-stage renal disease (ESRD) nephrology care was associated with lower mortality at both the patient and state levels among 443 761 incident ESRD patients identified in the USA between 2006 and 2010.
  
  
  RESULTS
  Overall, 33% of new ESRD patients had received no prior nephrology care, while 28% had received care for >12 months. At the patient level, predictors of >12 months of nephrology care included having health insurance, white race, younger age, diabetes, hypertension and US region. Longer pre-ESRD nephrology care was associated with lower first-year mortality (adjusted hazard ratio = 0.58 for >12 months versus no care; 95% confidence interval 0.57-0.59), higher albumin and hemoglobin, choice of peritoneal dialysis and native fistula and discussion of transplantation options. Living in a state with a 10% higher proportion of patients receiving >12 months of pre-ESRD care was associated with a 9.3% lower relative mortality rate, standardized for case mix (R (2) = 0.47; P < 0.001).
  
  
  CONCLUSIONS
  This study represents the largest cohort of incident ESRD patients to date. Although we did not follow patients before ESRD onset, our findings, both at the individual patient and state levels, reflect the importance of early nephrology care among those with chronic kidney disease.
authors.affiliation: Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Biostatistics , University of Michigan , Ann Arbor, MI , USA ; Center for Statistical Consultation and Research, University of Michigan , Ann Arbor, MI , USA.
authors.forename: Brenda W
authors.initials: BW
authors.lastname: Gillespie
authors.affiliation: Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor, MI , USA ; Department of Environmental Health Sciences , University of Michigan School of Public Health , Ann Arbor, MI , USA ; Department of Urology , University of Michigan Medical School , Ann Arbor, MI , USA.
authors.forename: Hal
authors.initials: H
authors.lastname: Morgenstern
authors.affiliation: EpidStat Institute , Ann Arbor, MI , USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Hedgeman
authors.affiliation: Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Internal Medicine , University of Michigan , Ann Arbor, MI , USA.
authors.forename: Anca
authors.initials: A
authors.lastname: Tilea
authors.affiliation: Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Biostatistics , University of Michigan , Ann Arbor, MI , USA.
authors.forename: Natalie
authors.initials: N
authors.lastname: Scholz
authors.affiliation: Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Biostatistics , University of Michigan , Ann Arbor, MI , USA.
authors.forename: Tempie
authors.initials: T
authors.lastname: Shearon
authors.affiliation: Division of Diabetes Translation , Centers for Disease Control and Prevention , Atlanta, GA , USA.
authors.forename: Nilka Rios
authors.initials: NR
authors.lastname: Burrows
authors.affiliation: Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Internal Medicine , University of Michigan , Ann Arbor, MI , USA.
authors.forename: Vahakn B
authors.initials: VB
authors.lastname: Shahinian
authors.affiliation: Henry Ford Health System , Detroit, MI , USA.
authors.forename: Jerry
authors.initials: J
authors.lastname: Yee
authors.affiliation: Department of Epidemiology , Emory University , Atlanta, GA , USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Plantinga
authors.affiliation: Department of Medicine , San Francisco General Hospital and University of California , San Francisco, CA , USA.
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
authors.affiliation: Department of Epidemiology , Emory University , Atlanta, GA , USA.
authors.forename: William
authors.initials: W
authors.lastname: McClellan
authors.affiliation: Arbor Research Collaborative for Health , Ann Arbor, MI , USA.
authors.forename: Bruce
authors.initials: B
authors.lastname: Robinson
authors.affiliation: Division of Diabetes Translation , Centers for Disease Control and Prevention , Atlanta, GA , USA.
authors.forename: Desmond E
authors.initials: DE
authors.lastname: Williams
authors.affiliation: Kidney Epidemiology and Cost Center , University of Michigan , Ann Arbor, MI , USA ; Department of Epidemiology , University of Michigan School of Public Health , Ann Arbor, MI , USA ; Department of Internal Medicine , University of Michigan , Ann Arbor, MI , USA.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Saran
keywords: dialysis; glomerular filtration rate; kidney transplantation; nephrology referral; vascular access