Treatment Center and Geographic Variability in Pre-ESRD Care Associate with Increased Mortality

Late referral of patients with chronic kidney disease is associated with increased morbidity and mortality, but the contribution of center-to-center and geographic variability of pre-ESRD nephrology care to mortality of patients with ESRD is unknown. We evaluated the pre-ESRD care of >30,000 incident hemodialysis patients, 5088 (17.8%) of whom died during follow-up (median 365 d). Approximately half (51.3%) of incident patients had received at least 6 mo of pre-ESRD nephrology care, as reported by attending physicians. Pre-ESRD nephrology care was independently associated with survival (odds ratio 1.54; 95% confidence interval 1.45 to 1.64). There was substantial center-to-center variability in pre-ESRD care, which was associated with increased facility-specific death rates. As the proportion of patients who were in a treatment center and receiving pre-ESRD nephrology care increased from lowest to highest quintile, the mortality rate decreased from 19.6 to 16.1% (P = 0.0031). In addition, treatment centers in the lowest quintile of pre-ESRD care were clustered geographically. In conclusion, pre-ESRD nephrology care is highly variable among treatment centers and geographic regions. Targeting these disparities could have substantial clinical impact, because the absence of ≥6 mo of pre-ESRD care by a nephrologist is associated with a higher risk for death.Nephrology care before starting hemodialysis (HD) is an important determinant of health status of patients with ESRD^1,2 and is associated with hypoalbuminemia,³ anemia,⁴ absence of a functioning arteriovenous vascular access,⁵ reduced quality of life,⁶ and decreased kidney transplantation.⁷ Delayed care is associated with progression of kidney disease^8,9 and increased mortality after start of HD.^10–13 Early nephrology referral for individuals with chronic kidney disease (CKD) is recommended^14,15 for creation of an arteriovenous fistula (AVF) 6 mo before the anticipated start of HD.¹⁶Despite these guidelines, incident patients with ESRD frequently present without antecedent nephrology care.¹⁷ Differences between treatment center and geographic areas, similar to variations reported for the care of prevalent patients with ESRD, are possible factors that might contribute to variable pre-ESRD care.^17–19 If clinically relevant center-to-center and geographic variations in pre-ESRD care exist, then interventions might be designed to reduce the risk for delayed or absent care. This report describes the variable prevalence and clinical consequences for both individual patients and their treatment center populations of delayed pre-ESRD nephrology care in a large population-based sample of incident patients with ESRD.