Early referral as an independent predictor of clinical outcome in end-stage renal disease on hemodialysis and continuous ambulatory peritoneal dialysis.
ABSTRACT To evaluate the influence of early nephrology referral on clinical outcome in patients on maintenance hemodialysis (HD) and peritoneal dialysis (PD).
This study retrospectively analyzed patients entering our HD and PD program from February 2000 to June 2003. Patients who presented to a nephrologist more than 6 months before starting dialysis were defined as early referral (ER). Meanwhile, patients transferred to the nephrology department less than 6 months before initial dialysis were considered late referral (LR). RESULTS HD GROUPS: Of 78 HD patients, 37 (47.1%) qualified for the ER group and 41 (52.6%) were designated to the LR group. The demographic data were analyzed for both the HD and PD groups. No significant differences in average age at dialysis, duration of hemodialysis, and gender were noted between these two groups. The same applied for the biochemical parameters in both groups. HD patients with early referral had significantly better survival (p < .05) as plotted with the Kaplan-Meier method. In univariate analysis by cox proportional hazards mode, the early referral in HD patients [Exp (Coef) = 0.426, P < .01] significantly influenced survival. The various variables were further examined by multivariate analysis, and early referral, hemoglobin, and age still significantly impacted patient survival (P < .05). CAPD GROUPS: The survival curve related to early referral in continuous ambulatory peritoneal dialysis (CADP) patient survival rate was significantly higher for the early referral groups (P < .05). In addition, a multivariate analysis adjusting for several potential risk factors found that referral time remained significantly associated with patient survival. In additional, hemoglobin and age were significant and independent predictors of mortality.
This study demonstrates that time between referral and starting dialysis is a predictor of survival for both HD and PD patients, with early referral being associated with longer survival time. These analytical results suggest that early referral before dialysis is important in determining long-term prognosis in HD and PD patients.
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ABSTRACT: Previous studies have analyzed the association between late versus early nephrologist referral (LR, ER) and poor clinical outcomes in patients with end-stage renal disease. We sought to determine whether these poor outcomes were causally related to LR, or whether LR was a proxy for poorer access to health care in general. An inception cohort of incident dialysis patients enrolled in the New Jersey Medicare or Medicaid programs was identified. Using a large number of demographic, clinical, and health care utilization covariates, propensity scores (PS) were then calculated to predict whether a given patient had been seen by a nephrologist at 90 d before first dialysis. Cox proportional hazards models were then built to test the association between timing of nephrologist referral and mortality during the first year of dialysis, using PS adjustment and matching to determine whether this association was confounded by other measures of reduced healthcare utilization. Neither adjustment for PS (HR = 1.31; 95% CI, 1.17 to 1.47) nor matching (HR = 1.40; 95% CI, 1.23 to 1.59) materially changed the initial 36% excess mortality in LR compared with ER patients (HR = 1.36; 95% CI, 1.22 to 1.51). Excess mortality among LR was limited to the first 3 mo of dialysis (HR = 1.75; 95% CI, 1.48 to 2.08) but not present thereafter (HR = 1.03; 95% CI, 0.84 to 1.25). Late nephrologist referral is an independent risk factor for early death on dialysis, even after controlling for other indicators of healthcare utilization. Further research is needed to identify patients at particular risk so that interventions to prevent early deaths on dialysis in LR patients can be developed and tested.Journal of the American Society of Nephrology 03/2003; 14(2):486-92. · 8.99 Impact Factor
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ABSTRACT: The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations. To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses. IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group). Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to "Relationships and Personal Development," "Intimacy," and "Instrumental" life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores. IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.Medical Care 11/2001; 39(10):1097-104. · 3.23 Impact Factor
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ABSTRACT: Dialysis is the most common renal replacement therapy for patients with end stage renal disease. This paper considers survival of dialysis patients, aiming to assess quality of renal replacement therapy at dialysis centers in Rio de Janeiro, Brazil, and to investigate differences in survival between health facilities. A Cox proportional hazards model, allowing for time-varying covariates and prevalent data, was the basic method used to analyze the survival of 11,579 patients on hemodialysis in 67 health facilities in Rio de Janeiro State from January 1998 until August 2001, using data obtained from routine information systems. A frailty random effects model was applied to investigate differences in mortality between health centers not explained by measured characteristics. The individual variables associated with the outcome were age and underlying disease, with diabetes being the main isolated risk factor. Considering covariates of the health unit, two factors were associated with performance: bigger units had on average better survival times than smaller ones and units which offered cyclic peritoneal dialysis performed less well than those that did not. There were significant frailty effects among centers, with relative risks varying between 0.24 and 3.15, and an estimated variance of 0.43. Routine assessment based on health registries of the outcome of any high technology medical treatment is extremely important in maintaining quality of care and in estimating the impact of changes in therapies, units, and patient profiles. The frailty model allowed estimation of variation in risk between centers not attributable to any measured covariates. This can be used to guide more specific investigation and changes in health policies related to renal transplant therapies.International Journal for Quality in Health Care 07/2003; 15(3):189-96. · 1.79 Impact Factor