Survival benefit of nephrologic care in patients with diabetes mellitus and chronic kidney disease

被引:80
|
作者
Tseng, Chin-Lin [1 ,2 ]
Kern, Elizabeth F. O. [3 ,4 ]
Miller, Donald R. [5 ,6 ]
Tiwari, Anjali [1 ,2 ]
Maney, Miriam [1 ]
Rajan, Mangala [1 ]
Pogach, Leonard [1 ,2 ]
机构
[1] Dept Vet Affairs New Jersey Hlth Care Syst, Dept Vet Affairs Ctr Healthcare Knowledge Managem, E Orange, NJ 07018 USA
[2] Univ Med & Dent New Jersey, Sch Med, Newark, NJ 07103 USA
[3] Case Western Reserve Univ, Louis Stokes Cleveland Dept Vet Affairs Med Ctr, Cleveland, OH 44106 USA
[4] Case Western Reserve Univ, Dept Med, Cleveland, OH 44106 USA
[5] Bedford Vet Affairs Med Ctr, Ctr Hlth Qual Outcomes & Econ Res, Bedford, MA USA
[6] Boston Univ, Sch Publ Hlth, Boston, MA 02215 USA
关键词
D O I
10.1001/archinternmed.2007.9
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
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 I 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.
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收藏
页码:55 / 62
页数:8
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