Multiple studies suggest that nephrology care before initiation of dialysis is associated with improved outcomes following the start of therapy, although it is likely that confounding limits these studies. Several studies, however, have reported that pre-dialysis nephrology care is very strongly associated with permanent vascular access placement; the use of mature fistulas and grafts at initiation likely improves outcomes, compared to those seen with the use of central venous catheters.
According to the Medical Evidence Report, roughly two in three patients have seen a nephrologist before initiating dialysis, with markedly higher and lower proportions in New England and the West South Central divisions, respectively. The Medical Evidence Report, however, lacks granularity about the nature of such care. According to Medicare claims for elderly patients (age ≥ 66), roughly three in four who saw a nephrologist before initiating dialysis actually received care in an outpatient setting. Nearly half received nephrology care in both inpatient and outpatient settings prior to initiation.
Percent of Patients Under Nephrology Care Before Starting Dialysis, According to the Medical Evidence Report; Overall & by U.S. Census Division
Setting of Pre-dialysis Nephrology Care, According to Medicare Claims
Setting of Pre-dialysis Cardiology Care, According to Medicare Claims
Nephrology Office Visits in the 6 Months Before Starting Dialysis
Among elderly patients with at least one office visit to a nephrologist during the six months before initiating dialysis, the mean number of visits per patient decreased modestly between 2008 and 2011, while the percentage with more than six visits fell sharply between 2009 and 2011. Evaluation and management (E & M) visits by both new and existing patients, however, appear to have increased in duration.
Coinciding with the publication of the TREAT study of darbepoetin, the percentage of patients receiving an erythropoiesis-stimulating agent (ESA), among those with at least one office visit to a nephrologist, fell steadily between 2008 and 2011. Among ESA users, the mean number of administrations and mean dose per administration both decreased between 2009 and 2010. Concurrently, administration of IV iron in the nephrology clinic decreased, although the absolute percentage of users was already low.