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Ultralate referral and presentation for renal replacement therapy: socioeconomic implications.
Am J Kidney Dis. 2005 Nov; 46(5):881-6.AJ

Abstract

BACKGROUND

Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern.

METHODS

During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR).

RESULTS

Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003).

CONCLUSION

Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations.

Authors+Show Affiliations

Renal Section, Clinical Research Center, Morehouse School of Medicine, Atlanta, GA 30310, USA. obialoc@msm.eduNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

16253728

Citation

Obialo, Chamberlain I., et al. "Ultralate Referral and Presentation for Renal Replacement Therapy: Socioeconomic Implications." American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, vol. 46, no. 5, 2005, pp. 881-6.
Obialo CI, Ofili EO, Quarshie A, et al. Ultralate referral and presentation for renal replacement therapy: socioeconomic implications. Am J Kidney Dis. 2005;46(5):881-6.
Obialo, C. I., Ofili, E. O., Quarshie, A., & Martin, P. C. (2005). Ultralate referral and presentation for renal replacement therapy: socioeconomic implications. American Journal of Kidney Diseases : the Official Journal of the National Kidney Foundation, 46(5), 881-6.
Obialo CI, et al. Ultralate Referral and Presentation for Renal Replacement Therapy: Socioeconomic Implications. Am J Kidney Dis. 2005;46(5):881-6. PubMed PMID: 16253728.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Ultralate referral and presentation for renal replacement therapy: socioeconomic implications. AU - Obialo,Chamberlain I, AU - Ofili,Elizabeth O, AU - Quarshie,Alexander, AU - Martin,Phyllis C, PY - 2005/05/25/received PY - 2005/08/03/accepted PY - 2005/10/29/pubmed PY - 2005/12/13/medline PY - 2005/10/29/entrez SP - 881 EP - 6 JF - American journal of kidney diseases : the official journal of the National Kidney Foundation JO - Am J Kidney Dis VL - 46 IS - 5 N2 - BACKGROUND: Clinical and metabolic complications of late referral (LR) for dialysis therapy have been well documented, but there is a paucity of data on its socioeconomic implications. This study examines the role of lifestyle and socioeconomic status on referral pattern. METHODS: During a 4-year period (1999 to 2002), we retrospectively reviewed records of all patients who initiated dialysis therapy at an urban tertiary-care center. Patients were classified into 3 categories according to the interval between first contact with a nephrologist and initiation of dialysis therapy: contact time of 3 months or longer indicates early referral (ER); 1 to less than 3 months, LR; and less than 1 month, ultralate referral (ULR). RESULTS: Of 460 patients (97% African Americans, 3% Hispanics), 212 patients (46%) were ULR, 168 patients (37%) were LR, and 80 patients (17%) were ER. Compared with ER and LR patients, those with ULR had significantly (P < 0.0001) lower hematocrits (23% versus 29% and 27%), serum albumin levels (3.1 versus 3.3 and 3.2 g/dL [31 versus 33 and 32 g/L]), and glomerular filtration rates (5 versus 8 and 7 mL/min/1.73 m2 [0.08 versus 0.13 and 0.12 mL/s/1.73 m2]), but greater rates of temporary dialysis catheter use (92% versus 39% and 70%) and mortality (40% versus 15% and 26%, respectively). Logistic regression analysis showed an association between mortality and homelessness (odds ratio, 3.8; P < 0.0001), polysubstance abuse (odds ratio, 2.3; P = 0.013), and alcoholism (odds ratio, 2.2; P = 0.009). Alcoholics (odds ratio, 2.5; P = 0.03), substance abusers (odds ratio, 5.5; P = 0.001), and the homeless/unemployed (odds ratio, 6.0; P = 0.004) were more likely to present as ULR cases. Patient-provided explanations for LR and ULR were denial (45%), unawareness of the presence of chronic kidney disease (30%), and economic difficulties (25%). Denial was more prevalent in LR (52%; P = 0.003) and ULR cases (39%; P = 0.003). CONCLUSION: Poor socioeconomic status is a major contributor to delayed referral. More efforts need to be directed at patient and physician chronic kidney disease educational awareness and improved health care access for inner-city and minority populations. SN - 1523-6838 UR - https://www.unboundmedicine.com/medline/citation/16253728/Ultralate_referral_and_presentation_for_renal_replacement_therapy:_socioeconomic_implications_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0272-6386(05)01106-6 DB - PRIME DP - Unbound Medicine ER -