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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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