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

William M. McClellan^*,, Haimanot Wasse^*, Ann C. McClellan, Adam Kipp, Lance A. Waller and Michael V. Rocco

^* Division of Nephrology and Departments of Epidemiology and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia; and Section on Nephrology, Wake Forest University, Winston-Salem, North Carolina

Correspondence: Dr. William McClellan, Emory University School of Medicine, Renal Division, Rollins School of Public Health, Room 476, 1518 Clifton Road, Atlanta, GA 30322. Phone: 404-727-6976; E-mail: wmcclel{at}sph.emory.edu

Received for publication June 20, 2008. Accepted for publication December 16, 2008.

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.

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Copyright © 2009 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673