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Titolo Treatment Center and Geographic Variability in Pre-ESRD Care Associate with Increased Mortality
Autore 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
Referenza J Am Soc Nephrol 2009; doi: 10.1681/ASN.2008060624
Contenuto 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.
Data 30.03.2009
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