Prevalence, Predictors, and Consequences of Late Nephrology Referral at a Tertiary Care Center PRADEEP ARORA,* GREGORIO T. OBRADOR,* ROBIN RUTHAZER, † ANNAMARIA T. KAUSZ,* KLEMENS B. MEYER,* CONSTANCE S. JENULESON, ‡ and BRIAN J. G. PEREIRA* Divisions of *Nephrology and † Clinical Care Research, New England Medical Center, and ‡ Dialysis Clinics, Inc., Boston, Massachusetts. Abstract. Despite improvements in dialysis care, mortality of patients with end-stage renal disease (ESRD) remains high. One factor that has thus far received little attention, but might contribute to morbidity and mortality, is the timing of referral to the nephrologist. This study examines the hypothesis that late referral of patients to the nephrologist might lead to sub- optimal pre-ESRD care. Clinical and laboratory data were obtained from the patient records and electronic databases of New England Medical Center, its affiliated dialysis unit (Di- alysis Clinics, Inc., Boston), and the office records of the outpatient nephrology clinic. Early (ER) and late (LR) referral were defined by the time of first nephrology encounter greater than or less than 4 mo, respectively, before initiation of dial- ysis. Multivariate models were built to explore factors associ- ated with LR, and whether LR is associated with hypoalbu- minemia or late initiation of dialysis. Of the 135 patients, 30 (22%) were referred late. There were no differences in age, gender, race, and cause of ESRD between ER and LR patients. However, there were significant differences in insurance cov- erage between these two groups. In the multivariate analysis, patients covered by health maintenance organizations were more likely to be referred late (odds ratio = 4.5) than patients covered by Medicare. Compared to ER, LR patients were more likely to have hypoalbuminemia (56% versus 80%), hematocrit 28% (33% versus 55%), and predicted GFR 5 ml/min per 1.73 m 2 (17% versus 40%) at the start of dialysis, and less likely to have received erythropoietin (40% versus 17%) or have a functioning permanent vascular access for the first hemodialysis (40% versus 4%). It is concluded that late referral to the nephrologist is common in the United States and is associated with poor pre-ESRD care. Pre-ESRD care of pa- tients treated by nephrologists was also less than ideal. The patient-, physician-, and system-related factors behind this observation are unclear. Meanwhile, pre-ESRD educational efforts need to target patients, generalists, and nephrologists. The prevalence and incidence of end-stage renal disease (ESRD) are increasing, and ESRD treatment consumes a sig- nificant proportion of health care resources in the United States. The prevalence of ESRD has more than doubled in the past decade, with a corresponding annual increase of 10% in the overall prevalence (1). The annual cost of treating ESRD patients is $14.5 billion, and is constantly increasing (2). De- spite the considerable resources committed to the care of ESRD patients and improvement in the overall quality of dialysis therapy, the mortality among dialysis patients remains high. The mean remaining life span is only 9.3 yr for patients beginning dialysis at age 40 and 4.3 yr for patients beginning dialysis at age 59 (3). Several investigators have demonstrated that increasing age, white race, male gender, nonrenal comorbidity, presence of malnutrition, and inadequate delivered dose of dialysis are independent predictors of mortality among dialysis patients (1,4 – 6). However, despite increasing attention to modifiable factors such as increased dose of dialysis and use of more biocompatible dialyzers, mortality among dialysis patients re- mains high (2). This has led to a search for other modifiable factors that could improve ESRD outcomes. Among factors that have received scant attention, but may significantly affect the morbidity and mortality of dialysis patients, are the timing and quality of care before initiation of dialysis (pre-ESRD care). Optimal pre-ESRD care involves early detection of progressive renal disease, intervention to retard its progression, prevention of uremic complications, attenuation of comorbid conditions, adequate preparation for ESRD therapy, and timely initiation of dialysis (7). However, it is not known whether patients referred to a nephrologist early receive better pre- ESRD care than those who are referred late. Theoretically, timely referral of patients with chronic renal failure (CRF) to a nephrologist is likely to result in an improved clinical condition and better preparation for initiation of dialysis. Indeed, data from Europe (8 –11) and South America (12) have shown that delayed referral is a significant problem, and is associated with a higher prevalence of uremic complication at the initiation of dialysis, with increased hospitalizations and higher cost of care. However, there is limited information available regarding Received August 19, 1998. Accepted December 8, 1998. Correspondence to Dr. Brian J. G. Pereira, Division of Nephrology, New England Medical Center, Box 391, 750 Washington Street, Boston, MA 02111. Phone: 617-636-0372; Fax: 617-636-8329; E-mail: brian.pereira@es.nemc.org 1046-6673/1006-1281 Journal of the American Society of Nephrology Copyright © 1999 by the American Society of Nephrology J Am Soc Nephrol 10: 1281–1286, 1999