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Survival Benefit of Nephrologic Care in Patients With Diabetes Mellitus and Chronic Kidney Disease
Chin-Lin Tseng, DrPH;
Elizabeth F. O. Kern, MD, MS;
Donald R. Miller, ScD;
Anjali Tiwari, MBBS, MS;
Miriam Maney, MA, CPHQ;
Mangala Rajan, MBA;
Leonard Pogach, MD, MBA
Arch Intern Med. 2008;168(1):55-62.
Background The association of nephrologic care and survival in patients with diabetes mellitus and chronic kidney disease is unknown.
Methods Using data from 1997 to 2000, we conducted a retrospective cohort study of Veterans Health Administration clinic users having diabetes mellitus and stage 3 or 4 chronic kidney disease. The baseline period was 12 months and median follow-up was 19.3 months. Degree of consistency of visits to a nephrologist, defined as the number of calendar quarters in which there was 1 visit or more (range, 0-4 quarters), and covariates were calculated from the baseline period. The outcome measure was dialysis-free death.
Results Of 39 031 patients, 70.0%, 22.4%, and 7.6% had early stage 3, late stage 3, and stage 4 chronic kidney disease, respectively, and 3.1%, 9.5%, and 28.2%, respectively, visited a nephrologist. Dialysis-free mortality rates were 9.6, 14.1, and 19.4, respectively, per 100 person-years. More calendar quarters with visits to a nephrologist were associated with lower mortality: adjusted hazard ratios were 0.80 (95% confidence interval, 0.67-0.97), 0.68 (95% confidence interval, 0.55-0.86), and 0.45 (95% confidence interval, 0.32-0.63), respectively, when the groups having 2, 3, and 4 visits were compared with those who had no visits. One visit only was not associated with a difference in mortality when compared with no visits (adjusted hazard ratio,1.02; 95% confidence interval, 0.89-1.16).
Conclusions The consistency of outpatient nephrologic care was independently associated in a graded fashion with lower risk of deaths in patients with diabetes and moderately severe to severe chronic kidney disease. However, only a minority of patients had any visits to a nephrologist.
Author Affiliations: Department of Veterans Affairs Center for Healthcare Knowledge Management, Department of Veterans Affairs New Jersey Health Care System, East Orange (Drs Tseng, Tiwari, and Pogach and Mss Maney and Rajan); University of Medicine & Dentistry of New Jersey Medical School, Newark (Drs Tseng, Tiwari, and Pogach); Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and Department of Medicine, Case Western Reserve University, Cleveland, Ohio (Dr Kern); and Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, and Boston University School of Public Health, Massachusetts (Dr Miller).
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