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Greater First-Year Survival on Hemodialysis in Facilities in Which Patients Are Provided Earlier and More Frequent Pre-nephrology Visits

Takeshi Hasegawa^*,,, Jennifer L. Bragg-Gresham, Shin Yamazaki, Shunichi Fukuhara, Tadao Akizawa^||, Werner Kleophas^¶, Roger Greenwood^**, and Ronald L. Pisoni

^* Division of Nephrology, Department of Internal Medicine, Fujiyoshida Municipal Hospital, Yamanashi, Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, and ^|| Department of Nephrology, Showa University School of Medicine, Tokyo, Japan; Arbor Research Collaborative for Health, Ann Arbor, Michigan; ^¶ Dialysezentrum Karlstrasse, Dusseldorf, Germany; and ^** Department of Renal Medicine, Lister Hospital, Stevenage, United Kingdom

Correspondence: Dr. Takeshi Hasegawa, Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Konoe-cho Yoshida, Sakyo-ku, Kyoto, 606-8501, Japan. Phone: +81-75-753-4646; Fax: +81-75-753-4644; E-mail: tahasegawa-npr{at}umin.net

Background and objectives: The aim of this study was to evaluate the relation between pre-nephrology visit (PNV) and 1-yr patient survival after hemodialysis (HD) induction.

Design, setting participants, & measurements: Data were analyzed from 8500 incident HD patients (on HD 30 d) in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases I and II. A visit to a nephrologist at least 1 mo before starting HD was regarded as PNV. Cox regression was used to estimate the adjusted hazard ratio (AHR) for mortality in the first year of HD in both patient- and facility-level analyses. All models were adjusted for age, sex, race, socioeconomic factors, cause of ESRD, 14 comorbid conditions, hemoglobin, serum albumin, and serum creatinine; accounted for facility clustering effects; and were stratified by country.

Results: In patient-level analysis, PNV was associated with significantly lower risk for death (AHR 0.57; P < 0.0001). Facility-level analysis also showed a significant lower risk for death in facilities with greater prevalence of PNV in both continuous models (AHR 0.92 per 10% greater facility mean %PNV; P < 0.0004) and in categorical models (AHR 0.71 for facilities with >90% of patients receiving PNV [first quartile] compared with facilities with <71% of patients receiving PNV [fourth quartile]; P = 0.001).

Conclusions: These results provide not only patient-level but also facility practice evidence that PNV is related to improved patient survival during the first year after initiation of HD, indicating the possible mortality benefits with more increased attention to PNV.