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Nephrologist Care and Mortality in Patients With Chronic Renal Insufficiency
Jerry Avorn, MD;
Rhonda L. Bohn, ScD;
Elliott Levy, MD, MPH;
Raisa Levin, MS;
William F. Owen, Jr, MD;
Wolfgang C. Winkelmayer, MD, ScD, MPH;
Robert J. Glynn, ScD
Arch Intern Med. 2002;162:2002-2006.
Background For patients with chronic renal insufficiency, rates of referral to
nephrologists are highly variable, and little is known about the effect of
such consultation on clinical outcomes. We sought to determine whether early
or frequent access to nephrologist care prior to the initiation of dialysis
was associated with a difference in mortality rates in the first year after
dialysis began.
Methods We identified all patients in the New Jersey Medicaid and Medicare programs
who began maintenance dialysis during a 6-year period and who had been diagnosed
with renal disease more than 12 months prior to dialysis. Use of nephrologist
services was documented during this 1-year period, along with other clinical
and sociodemographic variables. The outcome measure of our analysis was mortality
in the first year after initiation of dialysis.
Results From multivariate analyses, we found that patients who did not see a
nephrologist until 90 days or less before initiation of dialysis had a 37%
higher likelihood of death in the first year of dialysis compared with patients
with earlier referral (95% confidence interval, 1.22-1.52; P<.001). Similarly, those who saw a nephrologist on fewer than 5
occasions in the year prior to dialysis had a 15% higher mortality rate in
the first year of dialysis compared with those who had had 5 or more nephrologist
visits (95% confidence interval, 1.03-1.28; P = .01).
Conclusions For patients with long-standing renal disease, earlier consultation
with a nephrologist and more frequent specialist encounters is associated
with lower mortality in the first year of dialysis. These findings need to
be confirmed in younger and less indigent patients as well.
From the Division of Pharmacoepidemiology and Pharmacoeconomics (Drs
Avorn, Bohn, Winkelmayer, and Glynn and Ms Levin), Division of Nephrology
(Drs Levy and Owen), Department of Medicine, Brigham and Women's Hospital,
Harvard Medical School, Boston, Mass. Dr Levy is now with Bristol-Myers Squibb
Pharmaceutical Research Institute, Princeton, NJ, and Dr Owen is with Duke
Institute of Renal Outcomes Research and Health Policy, Duke University Medical
Center, Durham, NC.
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