Renal Division, Washington University School of Medicine, St Louis, MO 63110, USA.
Am J Kidney Dis. 2012 Mar;59(3 Suppl 2):S34-9. doi: 10.1053/j.ajkd.2011.11.020.
People with or at high risk of chronic kidney disease (CKD) are at increased risk of premature morbidity and mortality. We sought to examine the effect of care provided by a primary care physician (PCP) on survival for all participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) and the effect of care provided by a nephrologist on survival for KEEP participants with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2).
Provision of care by a PCP (n = 138,331) or nephrologist (n = 10,797) was defined using self-report of seeing that provider within the past year. Survival was ascertained by linking KEEP data to the Social Security Administration Death Master File. Multivariable Cox proportional hazards models examining the relationship between primary care and nephrologist provider status adjusted for age, sex, race, smoking status, education, health insurance, diabetes, cardiovascular disease, hypertension, cancer, albuminuria, body mass index, baseline eGFR, and hemoglobin level, with nephrology models further adjusting for calcium, phosphorus, and parathyroid hormone levels.
Of all participants, 70.9% (98,050 of 138,331) reported receiving PCP care; older age and female sex were associated with this care. During a median follow-up of 4.2 years, 4,836 deaths occurred. After multivariable adjustment, receiving PCP care and mortality were not associated (HR, 0.94; 95% CI, 0.86-1.03; P = 0.2). Of participants with eGFR <60 mL/min/1.73 m(2), 10.1% (1,095 of 10,797) reported receiving nephrology care; younger age and male sex were associated with receipt of nephrology care. During a mean follow-up of 2.2 years, 558 deaths occurred. After multivariable adjustment, nephrologist care was not associated with mortality (HR, 1.01; 95% CI, 0.75-1.36; P = 0.9). These associations were not modified by other specialist care (endocrinologist or cardiologist).
For all KEEP participants, neither PCP nor nephrology care was associated with improved survival. These results highlight the need to explore the connection between access to health care and outcomes in persons at high risk of or with CKD.
患有慢性肾脏病（CKD）或有发生 CKD 风险的人群，其过早发病和死亡的风险增加。我们试图探讨初级保健医生（PCP）提供的护理对全国肾脏基金会肾脏早期评估计划（KEEP）中所有参与者的生存的影响，以及肾脏病医生提供的护理对 KEEP 中估算肾小球滤过率（eGFR）＜60 mL/min/1.73 m 2的参与者的生存的影响。
通过自我报告在过去一年中看过该提供者，定义 PCP（n=138331）或肾脏病医生（n=10797）提供的护理。通过将 KEEP 数据与社会安全管理局死亡主文件链接来确定生存情况。多变量 Cox 比例风险模型检查初级保健和肾脏病医生提供者状态与年龄、性别、种族、吸烟状况、教育程度、医疗保险、糖尿病、心血管疾病、高血压、癌症、白蛋白尿、体重指数、基线 eGFR 和血红蛋白水平之间的关系，肾脏病模型进一步调整钙、磷和甲状旁腺激素水平。
在所有参与者中，70.9%（138331 名中的 98050 名）报告接受了 PCP 护理；年龄较大和女性与这种护理相关。在中位数为 4.2 年的随访期间，有 4836 人死亡。经过多变量调整后，接受 PCP 护理与死亡率无关（HR，0.94；95%CI，0.86-1.03；P=0.2）。在 eGFR＜60 mL/min/1.73 m 2的参与者中，10.1%（10797 名中的 1095 名）报告接受了肾脏病护理；年龄较小和男性与接受肾脏病护理相关。在平均 2.2 年的随访期间，有 558 人死亡。经过多变量调整后，肾脏病医生的护理与死亡率无关（HR，1.01；95%CI，0.75-1.36；P=0.9）。这些关联不受其他专科护理（内分泌科医生或心脏病专家）的影响。
对于所有 KEEP 参与者，PCP 护理和肾脏病护理均与生存改善无关。这些结果突出表明需要探索在高风险或患有 CKD 的人群中，获得医疗保健与结局之间的关系。
