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ARTICLE

The Timing of Specialist Evaluation in Chronic Kidney Disease and Mortality

Kraig S. Kinchen, MD, MSc; John Sadler, MD; Nancy Fink, MPH; Ronald Brookmeyer, PhD; Michael J. Klag, MD, MPH; Andrew S. Levey, MD; and Neil R. Powe, MD, MPH, MBA

17 September 2002 | Volume 137 Issue 6 | Pages 479-486

Background: Care for chronic renal failure involves management of complications and preparation for possible dialysis. Patients often are not evaluated by nephrologists in a timely manner.

Objective: To identify factors associated with late evaluation by a nephrologist and to assess whether late evaluation is associated with worse survival once patients develop end-stage renal disease (ESRD).

Design: National prospective cohort study.

Setting: 81 dialysis facilities throughout the United States.

Patients: 828 patients with new-onset ESRD.

Measurements: Time from first evaluation by a nephrologist to initiation of dialysis, classified as late (<4 months), intermediate (4 to 12 months), or early (>12 months); rate of death, from initiation of dialysis to an average of 2.2 years of follow-up; and demographic, clinical, and laboratory characteristics.

Results: After adjustment for potential confounders, late evaluation was more common among black men than white men (44.8% vs. 24.5%; P < 0.05), uninsured patients than insured patients (56.7% vs. 29.0%; P < 0.05) and patients with severe comorbid disease than those with mild comorbid disease (35.0% vs. 23.0%; P < 0.05). Compared with patients who had early evaluation, the risk for death was greater among patients evaluated late and was graded (hazard ratio, 1.3 [95% CI, 0.87 to 2.06] for patients with intermediate evaluation and 1.8 [CI, 1.21 to 2.61] for those with late evaluation) after adjustment for dialysis method, demographic characteristics, and socioeconomic status in Cox proportional-hazards regression analysis. After additional adjustment for such factors as the presence and severity of comorbid conditions, the association remained graded (hazard ratio, 1.2 [CI, 0.73 to 1.82] for patients evaluated at an intermediate point and 1.6 [CI, 1.04 to 2.39] for those evaluated late).

Conclusions: Late evaluation of patients with chronic renal failure by a nephrologist is associated with greater burden and severity of comorbid disease, black ethnicity, lack of health insurance, and shorter duration of survival.

Editors' Notes Context In the United States, the 5-year survival of patients undergoing dialysis is 29%. Early nephrologist evaluation is associated with better outcomes, but 25% of patients first see a nephrologist within a month of beginning dialysis. Contribution Late nephrology evaluation (<4 months before start of dialysis) was most common among black men, uninsured patients, and patients with severe comorbid illness. The later the first evaluation by a nephrologist, the greater the risk for death. Clinical Implications Clinicians need a system to remind them to refer patients at an early stage of chronic renal failure, especially black men, the uninsured, or patients with severe comorbid illness. –The Editors

 

Author and Article Information

From the Robert Wood Johnson Clinical Scholars Program and Welch Center for Prevention, Epidemiology, and Clinical Research, The Johns Hopkins University School of Medicine, Independent Dialysis Foundation, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and New England Medical Center, Boston, Massachusetts.

Acknowledgments: The authors thank the patients, staff, and medical directors of the participating clinics at Dialysis Clinic, Inc., New Haven CAPD, and St. Raphael's Hospital who contributed to the study.

Grant Support: The Choices for Healthy Outcomes in Caring for ESRD Study is supported by grant R01-HS-08365 from the Agency for Health Care Research and Quality, Rockville, Maryland, and by grant R01 DK59616 from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Kinchen was supported by the Robert Wood Johnson Clinical Scholars Program, and Dr. Powe (grant K24DK02643) and Dr. Klag (by grant K24DK02856) received grants from the National Institute of Diabetes and Digestive and Kidney Diseases.

Requests for Single Reprints: Neil R. Powe, MD, MPH, MBA, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205-2223; e-mail, npowe{at}jhmi.edu.

Current Author Addresses: Dr. Kinchen: Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285.

Dr. Sadler: Independent Dialysis Foundation, 840 Hollins Street, Baltimore, MD 21201.

Dr. Fink: Johns Hopkins University, 2024 East Monument Street, Baltimore, MD 21205.

Dr. Brookmeyer: Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205.

Dr. Klag: Johns Hopkins University, 2024 East Monument Street, Baltimore, MD 21205

Dr. Levey: Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111.

Dr. Powe: Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205-2223.

Author Contributions Conception and design: K.S. Kinchen, J. Sadler, N. Fink, M.J. Klag, A.S. Levey, N.R. Powe.

Analysis and interpretation of the data: K.S. Kinchen, R. Brookmeyer, A.S. Levey, N.R. Powe.

Drafting of the article: K.S. Kinchen, N. Fink, N.R. Powe.

Critical revision of the article for important intellectual content: K.S. Kinchen, J. Sadler, N. Fink, R. Brookmeyer, M.J. Klag, A.S. Levey, N.R. Powe.

Final approval of the article: K.S. Kinchen, N. Fink, M.J. Klag, A.S. Levey, N.R. Powe.

Statistical expertise: R. Brookmeyer, N.R. Powe.

Obtaining of funding: A.S. Levey, N.R. Powe.

Administrative, technical, or logistic support: N. Fink, N.R. Powe.

Collection and assembly of data: N. Fink, N.R. Powe.

Related articles in Annals:

Editorials
Specialist Evaluation in Chronic Kidney Disease: Too Little, Too Late
Norman G. Levinsky

Annals 2002 137: 542-543. [Full Text]  

Summaries for Patients
Timing of Evaluation by Specialists for Patients with Chronic Kidney Disease

Annals 2002 137: I-24. [Full Text]  

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