A report published online June 24 in JAMA Surgery, maps out the geographic gaps in end-stage renal disease care and quantifies the difference in death risk stemming from such regional disparities.
Using the he US Renal Data System, senior investigator Mahmoud Malas, MD, MH, an associate professor of surgery at the Johns Hopkins University School of Medicine, and his team tracked nearly 465,000 people with end-stage renal disease who started dialysis in the United States between 2006 and 2011, and found that the likelihood of having an AV fistula for dialysis access ranged from 11 to 22%, depending on where a person lived.
In addition, the analysis showed that no region met the target rate of treating at least half of its patients with the recommended form of access.
Overall, New England and the Pacific Northwest had the highest scores, with one in five patients getting fistula-based dialysis access. Florida, Texas and Southern California had the lowest scores, with slightly more than one in nine patients receiving fistula-based treatment. Mortality and survival followed the same geographic pattern, with patients in the high-scoring areas having a nearly 30% lower risk of dying, on average, compared with those in the bottom-scoring regions.
“Dialysis with an AV fistula is superior to other methods and offers a dramatic survival advantage,” says lead author Devin Zarkowsky, M.D., who conducted the research as a surgery resident at Johns Hopkins and is now a chief resident at the Dartmouth-Hitchcock Medical Center in New Hampshire. “The fact that fewer than one in five people start dialysis with a fistula is a real public health concern.
The importance of seeing a nephrologist
In the current study, receiving care from a kidney specialist, or a nephrologist, was the most potent factor in getting the right type of treatment. Patients who were seeing a nephrologist were 11 times more likely to get fistula-based dialysis than those followed by a general practitioner. Nearly three-quarters of patients in top-performing New England were under the care of a nephrologist. By contrast, slightly more than half of patients in the low-performing areas had access to specialized care.
The findings, the team says, underscore well-established regional gaps in availability of medical specialists of all types. And although not part of the current study, the researchers add, economic disparities have been long shown to fuel inequality in care, with people in more affluent regions faring decidedly better.
The results, the researchers say, suggest that efforts to improve dialysis access and speed up referrals to specialty care in low-scoring regions could be a powerful catalyst to closing geographic gaps in care and survival.
Specifically, the researchers recommend that:
- Primary care clinicians should pay close attention to subtle, early signs of kidney disease, particularly among those with known risk factors such as family history, hypertension or diabetes, and recognize worsening disease early, before patients go into full-blown kidney failure.
- Primary care clinicians should refer promptly to a nephrologist all patients whose kidneys filter at a capacity of 35% or less.
- Nephrologists should refer patients with declining function to surgeons for the creation of AV fistula before their kidney function dips under 25%.
- Primary care doctors, kidney specialists and surgeons should improve communication and coordination of care to avoid delays in the creating fistulas.
- Clinicians should educate patients on the importance of getting the right kind of dialysis and dispel the persistent myth that starting dialysis signals end of life.
“It’s not enough to tell a patient ‘You have kidney failure, and you need dialysis,'” Malas says. “We must do a better job explaining that dialysis is not the beginning of the end but a life-saving procedure and that its timing is critical.”