The Experts below are selected from a list of 360 Experts worldwide ranked by ideXlab platform
Wolfgang C. Winkelmayer - One of the best experts on this subject based on the ideXlab platform.
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predialysis nephrology care of older patients approaching end stage renal disease
JAMA Internal Medicine, 2011Co-Authors: Wolfgang C. Winkelmayer, Glenn M Chertow, Manjula Kurella TamuraAbstract:Currently, more than 570 000 US adults have end-stage renal disease (ESRD) and undergo maintenance dialysis or live with a functioning kidney transplant.1 More than 110 000 individuals initiate dialysis each year, almost half of whom are aged 65 years or older.1 Given the high risk of adverse outcomes from chronic kidney disease (CKD), timely referral to a Nephrologist has long been recommended.2 The potential benefits of timely nephrology referral include identification of reversible causes of CKD, provision of treatments that may slow the progression of CKD, management of the metabolic complications of advanced CKD, coordination of education regarding ESRD treatment options, and optimal preparation for the chosen dialysis modality or kidney transplantation. Delayed nephrology care has been associated with several unfavorable outcomes, including reduced access to peritoneal dialysis (PD) and kidney transplantation.3–7 Among patients who start hemodialysis, delayed nephrology care is associated with higher rates of dialysis initiation through a central venous catheter rather than an arteriovenous fistula or graft.8–10 Patients with CKD who consult a Nephrologist relatively late or infrequently also experience a considerable excess mortality rate after starting maintenance dialysis, especially during the first few months.11–13 Older adults are particularly at risk for experiencing delayed nephrology care.14 As early as 1994, national guidelines advised referral to a Nephrologist for women with a serum creatinine level of 1.5 mg/dL (to convert to micromoles per liter, multiply by 88.4) and men with a serum creatinine of 2.0 mg/dL or higher.2 Implementation of these guidelines was facilitated by the development of equations to estimate the glomerular filtration rate (GFR) from the serum creatinine concentration and by the development of a GFR-based CKD staging system.15,16 Subsequently, automatic reporting of estimated GFR (eGFR) by the Modification of Diet in Renal Disease formula has become routine in many health care systems17 and has increased recognition of CKD and referral of patients with CKD to Nephrologists.18 However, referral practices among patients who are approaching ESRD have not been studied carefully. Furthermore, previous studies examining nephrology referral patterns before ESRD have relied primarily on patient self-report or on the judgment of dialysis facility personnel, which may not accurately reflect actual referral practices. We designed the present study to test whether access to and timing of nephrology care among Medicare-insured older adults approaching ESRD have changed during the past decade and whether these putative changes have translated into improved patient outcomes. We hypothesized that, after controlling for changes in demographic trends and comorbid conditions, putative trends toward earlier referral for nephrology services would be associated with lower mortality rates.
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predialysis Nephrologist care and access to kidney transplantation in the united states
American Journal of Transplantation, 2007Co-Authors: Wolfgang C. Winkelmayer, William F Owen, Jyotsna Mehta, Anil Chandraker, Jerry AvornAbstract:Predialysis Nephrologist care is associated with morbidity and mortality in incident dialysis patients, but the relationship with access to kidney transplantation (KT) is unclear. From a national study of incident US dialysis patients, we identified 2253 patients with detailed information about predialysis care, sociodemographic characteristics and comorbidities. We used multivariate Cox proportional hazards models to study associations between predialysis nephrology care and two outcomes: time from first dialysis to the first day on the KT wait-list, and time to first KT. Two-thirds of patients first encountered a Nephrologist >3 months prior to dialysis and one-third
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a propensity analysis of late versus early Nephrologist referral and mortality on dialysis
Journal of The American Society of Nephrology, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Jerry AvornAbstract: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.
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The Nephrologist's role in the management of calcium-phosphorus metabolism in patients with chronic kidney disease
Kidney international, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, Jerry AvornAbstract:The Nephrologist's role in the management of calcium-phosphorus metabolism in patients with chronic kidney disease. Background In patients with chronic kidney disease (CKD), timely referral to a Nephrologist has been shown to improve outcomes, but the specific care measures mediating these superior outcomes have not been sufficiently described. Methods In a cohort of 3014 patients with CKD, we evaluated whether they had any indicators of calcium-phosphorus metabolism management prior to renal replacement therapy (RRT). These included measurement of parathyroid hormone (PTH) or vitamin D metabolites, or receipt of calcitriol or calcium-containing phosphate binders (CCPB) prior to RRT. Control patients without such care were selected by risk-set matching. We used multivariate conditional logistic regression analysis to test whether use of these interventions was associated with prior Nephrologist consultation. We then used Cox proportional hazards models to assess whether implementation of such care was associated with differences in 1-year mortality once RRT was instituted. Results Only 3.4% of CKD patients had their PTH assessed prior to RRT, and 0.3% had vitamin D status measured. Use of calcitriol (12.2%) and CCPBs (16%) was slightly more prevalent. Seeing a Nephrologist was highly associated with use of the tests and drugs studied (odds ratio, 1.28 to 6.46; all P values Conclusion Improvements in management of calcium-phosphorus metabolism in patients with CKD are attributable to Nephrologist care and appear to mediate the survival benefit seen in patients who see a Nephrologist relatively early in the course of their CKD.
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Nephrologist care and mortality in patients with chronic renal insufficiency
JAMA Internal Medicine, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Rhonda L Bohn, Elliott Levy, Robert J GlynnAbstract:Background For patients with chronic renal insufficiency, rates of referral to Nephrologists are highly variable, and little is known about the effect of such consultation on clinical outcomes. We sought to determine whether early or frequent access to Nephrologist care prior to the initiation of dialysis was associated with a difference in mortality rates in the first year after dialysis began. Methods We identified all patients in the New Jersey Medicaid and Medicare programs who began maintenance dialysis during a 6-year period and who had been diagnosed with renal disease more than 12 months prior to dialysis. Use of Nephrologist services was documented during this 1-year period, along with other clinical and sociodemographic variables. The outcome measure of our analysis was mortality in the first year after initiation of dialysis. Results From multivariate analyses, we found that patients who did not see a Nephrologist until 90 days or less before initiation of dialysis had a 37% higher likelihood of death in the first year of dialysis compared with patients with earlier referral (95% confidence interval, 1.22-1.52; P P = .01). Conclusions For patients with long-standing renal disease, earlier consultation with a Nephrologist and more frequent specialist encounters is associated with lower mortality in the first year of dialysis. These findings need to be confirmed in younger and less indigent patients as well.
Jerry Avorn - One of the best experts on this subject based on the ideXlab platform.
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predialysis Nephrologist care and access to kidney transplantation in the united states
American Journal of Transplantation, 2007Co-Authors: Wolfgang C. Winkelmayer, William F Owen, Jyotsna Mehta, Anil Chandraker, Jerry AvornAbstract:Predialysis Nephrologist care is associated with morbidity and mortality in incident dialysis patients, but the relationship with access to kidney transplantation (KT) is unclear. From a national study of incident US dialysis patients, we identified 2253 patients with detailed information about predialysis care, sociodemographic characteristics and comorbidities. We used multivariate Cox proportional hazards models to study associations between predialysis nephrology care and two outcomes: time from first dialysis to the first day on the KT wait-list, and time to first KT. Two-thirds of patients first encountered a Nephrologist >3 months prior to dialysis and one-third
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a propensity analysis of late versus early Nephrologist referral and mortality on dialysis
Journal of The American Society of Nephrology, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Jerry AvornAbstract: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.
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The Nephrologist's role in the management of calcium-phosphorus metabolism in patients with chronic kidney disease
Kidney international, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, Jerry AvornAbstract:The Nephrologist's role in the management of calcium-phosphorus metabolism in patients with chronic kidney disease. Background In patients with chronic kidney disease (CKD), timely referral to a Nephrologist has been shown to improve outcomes, but the specific care measures mediating these superior outcomes have not been sufficiently described. Methods In a cohort of 3014 patients with CKD, we evaluated whether they had any indicators of calcium-phosphorus metabolism management prior to renal replacement therapy (RRT). These included measurement of parathyroid hormone (PTH) or vitamin D metabolites, or receipt of calcitriol or calcium-containing phosphate binders (CCPB) prior to RRT. Control patients without such care were selected by risk-set matching. We used multivariate conditional logistic regression analysis to test whether use of these interventions was associated with prior Nephrologist consultation. We then used Cox proportional hazards models to assess whether implementation of such care was associated with differences in 1-year mortality once RRT was instituted. Results Only 3.4% of CKD patients had their PTH assessed prior to RRT, and 0.3% had vitamin D status measured. Use of calcitriol (12.2%) and CCPBs (16%) was slightly more prevalent. Seeing a Nephrologist was highly associated with use of the tests and drugs studied (odds ratio, 1.28 to 6.46; all P values Conclusion Improvements in management of calcium-phosphorus metabolism in patients with CKD are attributable to Nephrologist care and appear to mediate the survival benefit seen in patients who see a Nephrologist relatively early in the course of their CKD.
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Nephrologist care and mortality in patients with chronic renal insufficiency
JAMA Internal Medicine, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Rhonda L Bohn, Elliott Levy, Robert J GlynnAbstract:Background For patients with chronic renal insufficiency, rates of referral to Nephrologists are highly variable, and little is known about the effect of such consultation on clinical outcomes. We sought to determine whether early or frequent access to Nephrologist care prior to the initiation of dialysis was associated with a difference in mortality rates in the first year after dialysis began. Methods We identified all patients in the New Jersey Medicaid and Medicare programs who began maintenance dialysis during a 6-year period and who had been diagnosed with renal disease more than 12 months prior to dialysis. Use of Nephrologist services was documented during this 1-year period, along with other clinical and sociodemographic variables. The outcome measure of our analysis was mortality in the first year after initiation of dialysis. Results From multivariate analyses, we found that patients who did not see a Nephrologist until 90 days or less before initiation of dialysis had a 37% higher likelihood of death in the first year of dialysis compared with patients with earlier referral (95% confidence interval, 1.22-1.52; P P = .01). Conclusions For patients with long-standing renal disease, earlier consultation with a Nephrologist and more frequent specialist encounters is associated with lower mortality in the first year of dialysis. These findings need to be confirmed in younger and less indigent patients as well.
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delayed Nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure
Journal of Clinical Epidemiology, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, Robert J Glynn, Rhonda L Bohn, Elliot Levy, William F OwenAbstract:Abstract We sought to determine whether late referral to a Nephrologist in patients with chronic renal failure influences the adequacy of vascular access for hemodialysis. We analyzed data describing all health care encounters for all Medicare and Medicaid patients with end-stage renal failure in New Jersey between January 1991 and June 1996. Patients were required to have been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. In the resulting cohort of 2,398 incident hemodialysis patients, 35% had their first Nephrologist consultation ⩽90 days prior to initiation of dialysis. After controlling for demographic characteristics, socio-economic status and underlying renal disease, we found that patients who were referred to a Nephrologist >90 days prior to onset of hemodialysis were 38% more likely to have undergone predialysis vascular access surgery than those who were referred to a Nephrologist ⩽90 days before dialysis [OR: 1.38; 95% CI (1.15; 1.64)]. Similarly, patients referred late were 42% more likely to require central venous access for hemodialysis compared to those seen by a Nephrologist early [OR: 1.42; 95% CI (1.17; 1.71)]. Inadequate development of vascular access for renal replacement therapy in patients with late Nephrologist referral unnecessarily contributes to the burden of disease experienced by this vulnerable patient population.
Brenda R Hemmelgarn - One of the best experts on this subject based on the ideXlab platform.
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association between change in physician remuneration and use of peritoneal dialysis a population based cohort analysis
CMAJ Open, 2020Co-Authors: Aaron J Trachtenberg, Brenda R Hemmelgarn, Jianguo Zhang, Scott Klarenbach, Marcello Tonelli, Amity E Quinn, Peter Faris, Robert G Weaver, Braden J MannsAbstract:Background Health care payers are interested in policy-level interventions to increase peritoneal dialysis use in end-stage renal disease. We examined whether increases in physician remuneration for peritoneal dialysis were associated with greater peritoneal dialysis use. Methods We studied a cohort of patients in Alberta who started long-term dialysis with at least 90 days of preceding Nephrologist care between Jan. 1, 2001, and Dec. 31, 2014. We compared peritoneal dialysis use 90 days after dialysis initiation in patients cared for by fee-for-service Nephrologists and those cared for by salaried Nephrologists before and after weekly peritoneal dialysis remuneration increased from $0 to $32 (fee change 1, Apr. 1, 2002), $49 to $71 (fee change 2, Apr. 1, 2007), and $71 to $135 (fee change 3, Apr. 1, 2009). Remuneration for peritoneal dialysis remained less than hemodialysis until fee change 3. We performed a patient-level differences-in-differences logistic regression, adjusted for demographic characteristics and comorbidities, as well as an unadjusted interrupted time-series analysis of monthly outcome data. Results Our cohort included 4262 patients. There was no statistical evidence of a difference in the adjusted differences-indifferences estimator following fee change 1 (0.89, 95% confidence interval [CI] 0.44-1.81), 2 (1.15, 95% CI 0.73-1.83), or 3 (1.52, 95% CI 0.96-2.40). There was no significant difference in the immediate change or the trend over time in peritoneal dialysis use between fee-for-service and salaried groups following any of the fee changes in the interrupted time-series analysis. Interpretation We identified no statistical evidence of an increase in peritoneal dialysis use following increased fee-for-service remuneration for peritoneal dialysis. It remains unclear what role, if any, physician payment plays in selection of dialysis modality.
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impact of remote location on quality care delivery and relationships to adverse health outcomes in patients with diabetes and chronic kidney disease
Nephrology Dialysis Transplantation, 2012Co-Authors: Aminu K Bello, Brenda R Hemmelgarn, Braden J Manns, Matthew T James, Scott Klarenbach, Meng Lin, Stephanie Thompson, Marcello TonelliAbstract:Background. To investigate the relation of residence location, markers of good quality healthcare and adverse clinical outcomes in patients with diabetes and chronic kidney disease (CKD). Methods. We identified 31 337 individuals with diabetes and estimated glomerular filtration rate (eGFR) 15–59 mL/ min/1.73 m 2 from a population-based cohort (n= 1 278 375) of adults with serum creatinine measured at least once during 2005 or 2006 in Alberta, Canada. The study population was classified into categories based on travel distance by road from residence location to the closest Nephrologist: (0–50, 50.1–100, 100.1–200 and >200 km). Results. At follow-up, compared with those living within 50 km, remote dwellers were less likely to visit a Nephrologist, less likely to have hemoglobin A1c and urinary albumin measured within 1 year of the index eGFR, and less likely to receive an angiotensin converting enzyme inhibitor, angiotensin receptor blocker or statin (all P 200 km away from a Nephrologist, respectively (P< 0.0001). The hazard ratio of all-cause mortality increased with increasing distance: [1.07 (95% CI, 0.9– 1.2)], [1.1 (95% CI, 0.9–1.2)] and [1.2 (95% CI, 1.0–1.4)], respectively (P< 0.0001). Conclusions. Compared with those living closer to a Nephrologist, remote dwellers with diabetes and CKD were less likely to receive recommended quality care, and more likely to experience adverse health outcomes.
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impact of estimated gfr reporting on patients clinicians and health care systems a systematic review
American Journal of Kidney Diseases, 2011Co-Authors: Yoan K Kagoma, Brenda R Hemmelgarn, Ayub Akbari, Matthew A Weir, Arthur V Iansavichus, Uptal D Patel, Amit X Garg, Arsh K JainAbstract:Background Many laboratories now report estimated glomerular filtration rate (eGFR) when a serum creatinine measurement is ordered. A summary of the impact of eGFR reporting in health care systems around the world for which it has been adopted is lacking. Study Design Systematic review of MEDLINE, EMBASE, other major databases, and conference proceedings of major nephrology meetings. Setting & Population Any health care system in which eGFR reporting was introduced. Selection Criteria for Studies Published studies or abstracts reporting patient, clinician, or health system outcomes of eGFR reporting. Intervention eGFR reporting. Outcomes Volume of referrals or consults seen by Nephrologists, changes in characteristics of patients who were seen, and prescription rates of kidney-related medications. Results 22 studies (10 full text and 12 conference abstracts) were identified in 2004-2010 from 5 countries. Nephrologist referrals and consultations increased after eGFR reporting, ranging from 13%-270%. The greatest increases in referrals were seen for the elderly, females, and those with stage 3 or higher chronic kidney disease (eGFR 2 ). Change in renin-angiotensin-aldosterone system–blocking drug use ranged from increases of 0%-6%. Limitations Studies were highly variable in definition of outcomes. Reports were not available for many health care systems in which eGFR reporting was implemented. Conclusions eGFR reporting has been associated with greater identification of patients with decreased kidney function in most health care systems that have reported its impact.
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nephrology visits and health care resource use before and after reporting estimated glomerular filtration rate
JAMA, 2010Co-Authors: Brenda R Hemmelgarn, Jianguo Zhang, Braden J Manns, Matthew T James, Robert R Quinn, Pietro Ravani, Scott Klarenbach, Bruce F Culleton, Richard Krause, Laurel ThorlaciusAbstract:Context Laboratory reporting of estimated glomerular filtration rate (GFR) has been widely implemented, with limited evaluation. Objective To examine trends in Nephrologist visits and health care resource use before and after estimated GFR reporting. Design, Setting, and Patients Community-based cohort study (N = 1 135 968) with time-series analysis. Participants were identified from a laboratory registry in Alberta, Canada, and followed up from May 15, 2003, to March 14, 2007 (with estimated GFR reporting implemented October 15, 2004). Main Outcome Measure Nephrologist visits and patient management. Results Following estimated GFR reporting, the rate of first outpatient visits to a Nephrologist for patients with chronic kidney disease (CKD; estimated GFR 2 ) increased by 17.5 (95% confidence interval [CI], 16.5-18.6) visits per 10 000 CKD patients per month, corresponding to a relative increase from baseline of 68.4% (95% CI, 65.7%-71.2%). There was no association between estimated GFR reporting and rate of first Nephrologist visit among patients without CKD. Among patients with an estimated GFR of less than 30 mL/min/1.73 m 2 , the rate of first Nephrologist visits increased by 134.4 (95% CI, 60.0-208.7) visits per 10 000 patients per month. This increase was predominantly seen in women, patients aged 46 to 65 years as well as those aged 86 years or older, and those with hypertension, diabetes, and comorbidity. Reporting of estimated GFR was not associated with increased rates of internal medicine or general practitioner visits or increased use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers among patients with CKD and proteinuria or the subgroup limited to patients with diabetes. Conclusions Reporting of estimated GFR was associated with an increase in first Nephrologist visits, particularly among patients with more severe kidney dysfunction, women, middle-aged and very elderly patients, and those with comorbidities. Any effect on outcomes remains to be shown.
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when laboratories report estimated glomerular filtration rates in addition to serum creatinines nephrology consults increase
Kidney International, 2009Co-Authors: Arsh K Jain, Brenda R Hemmelgarn, Ian Mcleod, Cindy Y Huo, Meaghan S Cuerden, Ayub Akbari, Marcello Tonelli, Carl Van Walraven, Rob R Quinn, Matt J OliverAbstract:Serum creatinine alone can be difficult to interpret as a measure of kidney function such that chronic kidney disease might be under-recognized in the general population. In the province of Ontario, Canada, all outpatient laboratories now report estimated glomerular filtration rate (eGFR) in addition to serum creatinine. To determine the impact of this reporting on clinical practice, we linked health administrative data for more than 8 million adults of age 25 years or older over an almost 10-year period and conducted a population-based intervention analysis with seasonal time-series modeling to determine overall trends in the number and type of patients seen by Nephrologists. Compared to the period when only serum creatinines were reported, the number of patients seen in consultation by Nephrologists increased after eGFR reporting by an average of 24% (an absolute increase of 2.9 consults per 100,000 adults), an increase of about 23 consults per Nephrologist per year. The greatest increases were seen in women (39% increase) and those 80 years of age and older (58% increase). Our study found that eGFR reporting was associated with a sudden increase in the number of nephrology consults. However, it remains to be seen whether the routine reporting of eGFR results in improved treatment and outcomes for those with chronic kidney disease.
Raisa Levin - One of the best experts on this subject based on the ideXlab platform.
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a propensity analysis of late versus early Nephrologist referral and mortality on dialysis
Journal of The American Society of Nephrology, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Jerry AvornAbstract: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.
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The Nephrologist's role in the management of calcium-phosphorus metabolism in patients with chronic kidney disease
Kidney international, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, Jerry AvornAbstract:The Nephrologist's role in the management of calcium-phosphorus metabolism in patients with chronic kidney disease. Background In patients with chronic kidney disease (CKD), timely referral to a Nephrologist has been shown to improve outcomes, but the specific care measures mediating these superior outcomes have not been sufficiently described. Methods In a cohort of 3014 patients with CKD, we evaluated whether they had any indicators of calcium-phosphorus metabolism management prior to renal replacement therapy (RRT). These included measurement of parathyroid hormone (PTH) or vitamin D metabolites, or receipt of calcitriol or calcium-containing phosphate binders (CCPB) prior to RRT. Control patients without such care were selected by risk-set matching. We used multivariate conditional logistic regression analysis to test whether use of these interventions was associated with prior Nephrologist consultation. We then used Cox proportional hazards models to assess whether implementation of such care was associated with differences in 1-year mortality once RRT was instituted. Results Only 3.4% of CKD patients had their PTH assessed prior to RRT, and 0.3% had vitamin D status measured. Use of calcitriol (12.2%) and CCPBs (16%) was slightly more prevalent. Seeing a Nephrologist was highly associated with use of the tests and drugs studied (odds ratio, 1.28 to 6.46; all P values Conclusion Improvements in management of calcium-phosphorus metabolism in patients with CKD are attributable to Nephrologist care and appear to mediate the survival benefit seen in patients who see a Nephrologist relatively early in the course of their CKD.
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Nephrologist care and mortality in patients with chronic renal insufficiency
JAMA Internal Medicine, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Rhonda L Bohn, Elliott Levy, Robert J GlynnAbstract:Background For patients with chronic renal insufficiency, rates of referral to Nephrologists are highly variable, and little is known about the effect of such consultation on clinical outcomes. We sought to determine whether early or frequent access to Nephrologist care prior to the initiation of dialysis was associated with a difference in mortality rates in the first year after dialysis began. Methods We identified all patients in the New Jersey Medicaid and Medicare programs who began maintenance dialysis during a 6-year period and who had been diagnosed with renal disease more than 12 months prior to dialysis. Use of Nephrologist services was documented during this 1-year period, along with other clinical and sociodemographic variables. The outcome measure of our analysis was mortality in the first year after initiation of dialysis. Results From multivariate analyses, we found that patients who did not see a Nephrologist until 90 days or less before initiation of dialysis had a 37% higher likelihood of death in the first year of dialysis compared with patients with earlier referral (95% confidence interval, 1.22-1.52; P P = .01). Conclusions For patients with long-standing renal disease, earlier consultation with a Nephrologist and more frequent specialist encounters is associated with lower mortality in the first year of dialysis. These findings need to be confirmed in younger and less indigent patients as well.
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delayed Nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure
Journal of Clinical Epidemiology, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, Robert J Glynn, Rhonda L Bohn, Elliot Levy, William F OwenAbstract:Abstract We sought to determine whether late referral to a Nephrologist in patients with chronic renal failure influences the adequacy of vascular access for hemodialysis. We analyzed data describing all health care encounters for all Medicare and Medicaid patients with end-stage renal failure in New Jersey between January 1991 and June 1996. Patients were required to have been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. In the resulting cohort of 2,398 incident hemodialysis patients, 35% had their first Nephrologist consultation ⩽90 days prior to initiation of dialysis. After controlling for demographic characteristics, socio-economic status and underlying renal disease, we found that patients who were referred to a Nephrologist >90 days prior to onset of hemodialysis were 38% more likely to have undergone predialysis vascular access surgery than those who were referred to a Nephrologist ⩽90 days before dialysis [OR: 1.38; 95% CI (1.15; 1.64)]. Similarly, patients referred late were 42% more likely to require central venous access for hemodialysis compared to those seen by a Nephrologist early [OR: 1.42; 95% CI (1.17; 1.71)]. Inadequate development of vascular access for renal replacement therapy in patients with late Nephrologist referral unnecessarily contributes to the burden of disease experienced by this vulnerable patient population.
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determinants of delayed Nephrologist referral in patients with chronic kidney disease
American Journal of Kidney Diseases, 2001Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, Robert J Glynn, William F Owen, Jerry AvornAbstract:Abstract Late referral to Nephrologists of patients with chronic kidney disease (CKD) is a major public health problem because it is prevalent and associated with increased morbidity, mortality, and greater healthcare costs. To identify factors associated with delayed Nephrologist referral (first Nephrologist visit P P = 0.002), and the absence of certain comorbidities: hypertension ( P P P = 0.005), and diabetes ( P = 0.02). Associations of late referral with male sex ( P = 0.07) and lower socioeconomic status ( P = 0.09) were of borderline significance. Patients who were predominantly cared for by a general internist were more likely to be referred late to a Nephrologist compared with those cared for by a family or primary care practitioner ( P = 0.002) or another subspecialist ( P = 0.019). These findings suggest that several factors increase the risk that patients with CKD will have the first Nephrologist consultation excessively late in the course of their disease. Although timely access to Nephrologist services is important for all patients with advanced CKD, this is of particular concern in older patients, those in certain minority populations, and those in whom the absence of comorbidity may provide a false sense of true risk status. © 2001 by the National Kidney Foundation, Inc.
William F Owen - One of the best experts on this subject based on the ideXlab platform.
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predialysis Nephrologist care and access to kidney transplantation in the united states
American Journal of Transplantation, 2007Co-Authors: Wolfgang C. Winkelmayer, William F Owen, Jyotsna Mehta, Anil Chandraker, Jerry AvornAbstract:Predialysis Nephrologist care is associated with morbidity and mortality in incident dialysis patients, but the relationship with access to kidney transplantation (KT) is unclear. From a national study of incident US dialysis patients, we identified 2253 patients with detailed information about predialysis care, sociodemographic characteristics and comorbidities. We used multivariate Cox proportional hazards models to study associations between predialysis nephrology care and two outcomes: time from first dialysis to the first day on the KT wait-list, and time to first KT. Two-thirds of patients first encountered a Nephrologist >3 months prior to dialysis and one-third
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a propensity analysis of late versus early Nephrologist referral and mortality on dialysis
Journal of The American Society of Nephrology, 2003Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Jerry AvornAbstract: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.
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Nephrologist care and mortality in patients with chronic renal insufficiency
JAMA Internal Medicine, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, William F Owen, Rhonda L Bohn, Elliott Levy, Robert J GlynnAbstract:Background For patients with chronic renal insufficiency, rates of referral to Nephrologists are highly variable, and little is known about the effect of such consultation on clinical outcomes. We sought to determine whether early or frequent access to Nephrologist care prior to the initiation of dialysis was associated with a difference in mortality rates in the first year after dialysis began. Methods We identified all patients in the New Jersey Medicaid and Medicare programs who began maintenance dialysis during a 6-year period and who had been diagnosed with renal disease more than 12 months prior to dialysis. Use of Nephrologist services was documented during this 1-year period, along with other clinical and sociodemographic variables. The outcome measure of our analysis was mortality in the first year after initiation of dialysis. Results From multivariate analyses, we found that patients who did not see a Nephrologist until 90 days or less before initiation of dialysis had a 37% higher likelihood of death in the first year of dialysis compared with patients with earlier referral (95% confidence interval, 1.22-1.52; P P = .01). Conclusions For patients with long-standing renal disease, earlier consultation with a Nephrologist and more frequent specialist encounters is associated with lower mortality in the first year of dialysis. These findings need to be confirmed in younger and less indigent patients as well.
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delayed Nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure
Journal of Clinical Epidemiology, 2002Co-Authors: Jerry Avorn, Wolfgang C. Winkelmayer, Raisa Levin, Robert J Glynn, Rhonda L Bohn, Elliot Levy, William F OwenAbstract:Abstract We sought to determine whether late referral to a Nephrologist in patients with chronic renal failure influences the adequacy of vascular access for hemodialysis. We analyzed data describing all health care encounters for all Medicare and Medicaid patients with end-stage renal failure in New Jersey between January 1991 and June 1996. Patients were required to have been diagnosed with renal disease at least 1 year prior to onset of hemodialysis. In the resulting cohort of 2,398 incident hemodialysis patients, 35% had their first Nephrologist consultation ⩽90 days prior to initiation of dialysis. After controlling for demographic characteristics, socio-economic status and underlying renal disease, we found that patients who were referred to a Nephrologist >90 days prior to onset of hemodialysis were 38% more likely to have undergone predialysis vascular access surgery than those who were referred to a Nephrologist ⩽90 days before dialysis [OR: 1.38; 95% CI (1.15; 1.64)]. Similarly, patients referred late were 42% more likely to require central venous access for hemodialysis compared to those seen by a Nephrologist early [OR: 1.42; 95% CI (1.17; 1.71)]. Inadequate development of vascular access for renal replacement therapy in patients with late Nephrologist referral unnecessarily contributes to the burden of disease experienced by this vulnerable patient population.
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determinants of delayed Nephrologist referral in patients with chronic kidney disease
American Journal of Kidney Diseases, 2001Co-Authors: Wolfgang C. Winkelmayer, Raisa Levin, Robert J Glynn, William F Owen, Jerry AvornAbstract:Abstract Late referral to Nephrologists of patients with chronic kidney disease (CKD) is a major public health problem because it is prevalent and associated with increased morbidity, mortality, and greater healthcare costs. To identify factors associated with delayed Nephrologist referral (first Nephrologist visit P P = 0.002), and the absence of certain comorbidities: hypertension ( P P P = 0.005), and diabetes ( P = 0.02). Associations of late referral with male sex ( P = 0.07) and lower socioeconomic status ( P = 0.09) were of borderline significance. Patients who were predominantly cared for by a general internist were more likely to be referred late to a Nephrologist compared with those cared for by a family or primary care practitioner ( P = 0.002) or another subspecialist ( P = 0.019). These findings suggest that several factors increase the risk that patients with CKD will have the first Nephrologist consultation excessively late in the course of their disease. Although timely access to Nephrologist services is important for all patients with advanced CKD, this is of particular concern in older patients, those in certain minority populations, and those in whom the absence of comorbidity may provide a false sense of true risk status. © 2001 by the National Kidney Foundation, Inc.