Guofen Yan1, Alfred K Cheung2, Tom Greene3, Alison J Yu4, M Norman Oliver5, Wei Yu6, Jennie Z Ma6, Keith C Norris7. 1. Departments of Public Health Sciences and guofen.yan@virginia.edu. 2. Divisions of Nephrology and Hypertension and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah; 3. Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah; 4. Keck School of Medicine, University of Southern California, Los Angeles, California; and. 5. Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia; 6. Departments of Public Health Sciences and. 7. Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, California.
Abstract
BACKGROUND AND OBJECTIVES: Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care (≥12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years). RESULTS: The average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P<0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation. CONCLUSIONS: Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.
BACKGROUND AND OBJECTIVES: Although multiple factors influence access to nephrologist care in patients with CKD stages 4-5, the geographic determinants within the United States are incompletely understood. In this study, we examined interstate differences in nephrologist care among patients approaching ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This national, population-based analysis included 373,986 adult patients from the US Renal Data System, who initiated maintenance dialysis between 2005 and 2009. Multilevel logistic regression was used to examine interstate variation in nephrologist care (≥12 months before ESRD) for overall and four race-age subpopulations (black or white and older or younger than 65 years). RESULTS: The average state-level probability of having received nephrologist care in all states combined was 28.8% (95% confidence interval, 25.2% to 32.7%) overall and was lowest (24.3%) in the younger black subpopulation. Even at these lower levels, state-level probabilities varied considerably across states in overall and subpopulations (all P<0.001). Overall, excluding the states in the upper and lower five percentiles, the remaining states had a probability of receiving care that varied from 18.5% to 41.9%. The lower probability of receiving nephrologist care for blacks than whites among younger patients noted in most states was attenuated in older patients. Geographically, all New England states and most Midwest states had higher than average probability, whereas most Middle Atlantic and Southern states had lower than average probability. After controlling for patient factors, three state-characteristic categories, including general healthcare access measured by percentage of uninsured persons and Medicaid program performance scores, preventive care measured by percentage of receiving recommended preventive care, and socioeconomic status, contributed 55%-66% of interstate variation. CONCLUSIONS:Patients living in states with better health service and socioeconomic characteristics were more likely to receive predialysis nephrologist care. The reported national black-white difference in nephrologist care was primarily driven by younger black patients being the least likely to receive care.
Authors: Jerry Avorn; Rhonda L Bohn; Elliott Levy; Raisa Levin; William F Owen; Wolfgang C Winkelmayer; Robert J Glynn Journal: Arch Intern Med Date: 2002-09-23
Authors: Devin S Zarkowsky; Isibor J Arhuidese; Caitlin W Hicks; Joseph K Canner; Umair Qazi; Tammam Obeid; Eric Schneider; Christopher J Abularrage; Julie A Freischlag; Mahmoud B Malas Journal: JAMA Surg Date: 2015-06 Impact factor: 14.766
Authors: David R Arday; Barbara B Fleming; Dana K Keller; Peter W Pendergrass; Robert J Vaughn; James M Turpin; David A Nicewander Journal: Diabetes Care Date: 2002-12 Impact factor: 19.112
Authors: Kraig S Kinchen; John Sadler; Nancy Fink; Ronald Brookmeyer; Michael J Klag; Andrew S Levey; Neil R Powe Journal: Ann Intern Med Date: 2002-09-17 Impact factor: 25.391
Authors: Andrew S Levey; Josef Coresh; Ethan Balk; Annamaria T Kausz; Adeera Levin; Michael W Steffes; Ronald J Hogg; Ronald D Perrone; Joseph Lau; Garabed Eknoyan Journal: Ann Intern Med Date: 2003-07-15 Impact factor: 25.391
Authors: Mark J Sarnak; Andrew S Levey; Anton C Schoolwerth; Josef Coresh; Bruce Culleton; L Lee Hamm; Peter A McCullough; Bertram L Kasiske; Ellie Kelepouris; Michael J Klag; Patrick Parfrey; Marc Pfeffer; Leopoldo Raij; David J Spinosa; Peter W Wilson Journal: Circulation Date: 2003-10-28 Impact factor: 29.690
Authors: Keith C Norris; Sandra F Williams; Connie M Rhee; Susanne B Nicholas; Csaba P Kovesdy; Kamyar Kalantar-Zadeh; L Ebony Boulware Journal: Semin Dial Date: 2017-03-09 Impact factor: 3.455
Authors: Meera N Harhay; Ryan M McKenna; Suzanne M Boyle; Karthik Ranganna; Lissa Levin Mizrahi; Stephen Guy; Gregory E Malat; Gary Xiao; David J Reich; Michael O Harhay Journal: Clin J Am Soc Nephrol Date: 2018-06-21 Impact factor: 8.237
Authors: Brian M Brady; Meera V Ragavan; Melora Simon; Glenn M Chertow; Arnold Milstein Journal: J Am Soc Nephrol Date: 2019-11-14 Impact factor: 10.121