Provider and Care Characteristics Associated with Timing of Dialysis Initiation

Abstract

SummaryBackground and objectives There is a trend in the United States to maintenance dialysis initiation at higher levels of estimated GFR. This study aimed to determine whether provider characteristics and pre-ESRD nephrology care and vascular access are independently associated with higher estimated GFR at initiation.Design, setting, participants, & measurements This retrospective cohort study used US Renal Data System data for patients who initiated dialysis in 2006 (n=83,621) and American Medical Association Physician Master File data for provider characteristics. Patient characteristics and estimated GFR were defined, and providers at dialysis initiation were identified. Earlier dialysis initiation was defined as initiation at estimated GFR.10 ml/min per 1.73 m 2 . Nephrologist density per 100 ESRD patients was calculated by Health Service Area in 2006. Associations between provider characteristics and estimated GFR were determined using logistic regression and linear regression models, accounting for provider clustering.Results Of the cohort, 47.8% of patients initiated dialysis at estimated GFR.10 ml/min per 1.73 m 2 , and 16.2% of patients initiated dialysis at estimated GFR$15 ml/min per 1.73 m 2 . Predialysis nephrologist care for 0-12 months was associated with greater odds of earlier initiation compared with no care. Patients initiating with an arteriovenous fistula or graft were more likely to initiate earlier than patients initiating with a catheter. Provider sex was not associated with timing of dialysis initiation as measured by estimated GFR. Care by providers who graduated from nondomestic medical schools was associated with greater odds of earlier initiation. Greater provider experience was associated with lower likelihood of earlier initiation. ConclusionThis study supports the hypothesis that provider factors are associated with timing of dialysis initiation in the United States.

What Drives Early Dialysis Initiation and How Do We Optimize Timing of RRT?

“…Many of the specific patient characteristics associated with earlier dialysis initiation are similar to those previously observed in United States cohorts (2,7,9), and include female sex and presence of comorbidities. Prior studies have also suggested that patients with congestive heart failure initiate dialysis at higher eGFR values, likely to assist in the management of the patient's volume status (2,7).…”

“…Many of the specific patient characteristics associated with earlier dialysis initiation are similar to those previously observed in United States cohorts (2,7,9), and include female sex and presence of comorbidities. Prior studies have also suggested that patients with congestive heart failure initiate dialysis at higher eGFR values, likely to assist in the management of the patient's volume status (2,7). It is likely that in Canada, similar to the United States, acceptance of older and sicker patients for dialysis therapy has contributed to the trend of rising eGFR at dialysis initiation because these patients typically are unable to tolerate uremia to the same degree as younger patients and they may have artificially higher eGFR estimates from their reduced muscle mass.…”

“…Several factors have been hypothesized to contribute to the reported increase in eGFR at dialysis initiation, including greater acceptance of older and sicker patients with multiple comorbidities for dialysis intervention, a belief that of earlier dialysis initiation is associated with patient benefit, eGFR reporting and reliance on eGFR values to guide timing of dialysis initiation, misinterpretation of clinical practice guidelines, a desire to simplify management of CKD complications, and a greater financial reimbursement to providers associated with dialysis compared with CKD care (1,2). Prior studies have evaluated both patient and provider characteristics associated with timing of dialysis initiation (2,7). In this issue of CJASN, Sood et al aimed to determine how patient, facility, and geographic characteristics influence the variation of eGFR at dialysis initiation across Canada (8).…”

“…Similarly, in the United States, the incidence of treated ESRD, particularly among elderly patients and patients with multiple comorbid conditions, is highest in regions with the highest intensity of end-of life care (12). Slinin et al found a weak association between density of nephrologists and eGFR at dialysis initiation: Patients living in areas with lower or higher nephrologist density were less likely to initiate dialysis earlier than patients living in areas with 1-1.5 nephrologists per 100 ESRD patients (7). Possibly, areas differ in their capacity to accommodate patients with ESRD, competition for patients, incentive to initiate patients at lower eGFRs, and health care intensity.…”

The Ethics of Chronic Dialysis for the Older Patient

“…Those concerns must be weighed against the harm of placing fistulas in people who are never going to need them (55) and that may never mature (56). In addition, the presence of a mature fistula appears to be associated with a lower threshold to initiate hemodialysis (57). Patients can follow variable trajectories with CKD, which can help inform the transition point from observation to hemodialysis preparation (58).…”