Kidney disease patients are at a much increased risk of death when they have delays getting to a specialist, a Johns Hopkins-led study shows. Delays occur more often among black males, the uninsured and those who have multiple illnesses.
Results of the study, published in the Sept. 17 issue of the Annals of Internal Medicine, show that a third of chronic kidney disease patients were evaluated by a nephrologist only four months before having to start life-saving dialysis treatment. Those evaluated late were more likely to die within two years after starting dialysis. Delayed evaluation typically is associated with a higher risk of unplanned first dialysis and complications as well as increased hospital costs and length of stay.
While the study did not examine reasons for the delay in getting specialty care, senior author Neil R. Powe says these probably include poor access to primary care, delayed or absent referral to a specialist from a primary care doctor and patients' lack of information about the importance of early intervention.
"There also are many people who have chronic kidney disease and may not know it, so they may not be under a physician's care," says Powe, director of Hopkins' Welch Center for Prevention, Epidemiology and Clinical Research. "We need to get the condition on the radar screen, especially when there's a medical history of high blood pressure or diabetes, so both patients and physicians are more aware of the consequences and opportunities to intervene. These patients should be under the care of a doctor and should talk to their doctors about seeing a nephrologist before their disease progresses to the point at which they need dialysis."
Powe and colleagues examined data from the choices for healthy outcomes in caring for end-stage renal disease study, known as CHOICE, a Hopkins effort that followed more than 1,000 dialysis patients nationwide between October 1995 and June 1998. For this study, they reviewed information on 828 patients just starting dialysis, asking them to complete a questionnaire on their medical and social history and provide the month and year in which they first visited a nephrologist.
They also compared the time between each patient's first visit to a nephrologist and the start of his or her dialysis program. They defined early evaluation as first seeing a nephrologist more than a year before the start of dialysis and late evaluation as first seeing a nephrologist less than four months before dialysis. Patient survival rates were tracked for two years.
Thirty percent of patients were seen by a nephrologist less than four months prior to starting dialysis, compared to 22 percent evaluated between four and 12 months before dialysis, and 48 percent evaluated more than a year before dialysis. Late evaluation was more common among black men than white men (45 percent vs. 25 percent), uninsured patients than insured patients (57 percent vs. 29 percent) and patients with severe co-existing disease than those with mild or no co-existing disease (35 percent vs. 23 percent). Those evaluated late were less likely to have received erythropoeitin, a hormone necessary to boost red blood cell production.
During an average follow-up period of 2.2 years, 201 of the patients died. Among those who were evaluated late, death rates were 13 percent one year after starting dialysis and 28 percent two years after starting dialysis. By comparison, among those evaluated early, the death rates were 4 percent and 15 percent, respectively.
Approximately 8 million people in the United States have moderate kidney disease, and another 300,000 have end-stage renal disease, or ESRD, Powe says. Annual U.S. spending related to treatment of ESRD exceeds $15 billion. The patient population studied was 55 percent male, 28 percent black and 65 percent younger than age 65.
The study was supported by the Agency for Healthcare Research and Quality, the Robert Wood Johnson Clinical Scholars Program and the National Institute of Diabetes and Digestive and Kidney Diseases. Co-authors were Nancy Fink, Ronald Brookmeyer and Michael J. Klag, of Hopkins; Kraig S. Kinchen, of Eli Lilly; John Sadler, of the Independent Dialysis Foundation of Baltimore; and Andrew S. Levey, of Tufts-New England Medical Center, Boston. Kinchen was at Hopkins when the study was completed.
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