Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA 22908, USA.
Clin J Am Soc Nephrol. 2013 Apr;8(4):610-8. doi: 10.2215/CJN.07780812. Epub 2013 Mar 14.
Pre-ESRD care is an important predictor of outcomes in patients undergoing long-term dialysis. This study examined the extent of variation in receiving pre-ESRD care and black-white disparities across urban and rural counties.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Participants were 404,622 non-Hispanic white and black patients aged >18 years who began dialysis between 2005 and 2010 and resided in 3076 counties from the U.S. Renal Data System. The counties were grouped into large metropolitan, medium/small metropolitan, suburban, and rural counties. Pre-ESRD care indicators included receipt of nephrologist care at least 6 or 12 months before ESRD, dietitian care, use of arteriovenous fistula at first outpatient dialysis session, and use of erythropoiesis-stimulating agents (ESAs) in patients with hemoglobin level < 10 g/dl.
Large metropolitan and rural counties had lower percentages of patients who received pre-ESRD nephrologist care (25.7% and 26.9% for nephrologist care > 12 months), compared with the higher percentage in medium/small metropolitan counties (31.6%; both P<0.001). For both races, nonmetropolitan patients had poorer access to dietitian care and lower ESA use than metropolitan patients. Consistently in all four geographic areas, black patients received less care than their white counterparts. The unadjusted odds ratios of black versus white patients in receiving nephrologist care for >12 months before ESRD were 0.66 (95% confidence interval [CI], 0.61-0.72) in large metropolitan counties and 0.79 (95% CI, 0.69-0.90) in rural counties. The patterns remained, albeit attenuated, after adjustment for patient factors.
The receipt of pre-ESRD care, with blacks receiving less care, varies among geographic areas defined by urban/rural characteristics.
终末期肾病（ESRD）前的护理是接受长期透析治疗的患者预后的重要预测指标。本研究旨在评估接受 ESRD 前护理的程度以及城乡各县之间的黑人和白人之间的差异。
设计、地点、参与者和测量：参与者为 404622 名年龄>18 岁的非西班牙裔白人和黑人患者，他们在 2005 年至 2010 年间开始接受透析治疗，居住在美国肾脏数据系统中的 3076 个县。这些县被分为大城市、中/小城市、郊区和农村县。ESRD 前护理的指标包括在 ESRD 前至少 6 或 12 个月接受肾病医生护理、营养师护理、在首次门诊透析时使用动静脉瘘以及在血红蛋白水平<10g/dl 的患者中使用促红细胞生成素刺激剂（ESA）。
与大都市和县（25.7%和 26.9%接受超过 12 个月的肾病医生护理）相比，大城市和农村县接受 ESRD 前肾病医生护理的患者比例较低（31.6%；均 P<0.001）。对于两种族裔，非大都市县的患者获得营养师护理和 ESA 使用率均低于大都市县的患者。在所有四个地理区域，黑人患者接受的护理都少于白人患者。在未经调整的情况下，黑人患者接受 ESRD 前超过 12 个月的肾病医生护理的可能性是白人患者的 0.66（95%置信区间[CI]，0.61-0.72），在农村县为 0.79（95% CI，0.69-0.90）。在调整患者因素后，这些模式仍然存在，尽管有所减弱。
接受 ESRD 前护理的情况因城乡特征定义的地理区域而异，黑人接受的护理较少。
