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Poverty Impacts Pre-Dialysis Care

WASHINGTON - The wealth or poverty of kidney disease
patients’ communities impacts the quality of care patients receive before starting
dialysis, according to a study appearing in an upcoming issue of the Journal of the
American Society Nephrology (JASN). The results suggest that medical professionals
need to improve care for patients who have not yet started dialysis.
For patients with end-stage renal disease (ESRD) who must begin the use of dialysis to
do the work their kidneys can no longer do, experts strongly recommend creating an
arteriovenous fistula (AVF). An AVF connects a vein and an artery, usually in the forearm,
to allow an efficient and convenient connection to a dialysis machine, and to provide a
long-lasting site through which blood can be removed and returned.
Research demonstrates substantial variations in the care that kidney disease patients
receive before beginning dialysis. William McClellan, MD (Emory University) and his
colleagues studied the degree to which AVF use in kidney disease patients is associated
with the level of poverty in the county where a treatment center is located.
The investigators studied 28,135 patients who were treated by 1,127 dialysis centers
within 16 states between June 1, 2005 and May 31, 2006. They found that among newly
identified dialysis patients at treatment centers in poorer communities, patients were
less likely to receive an AVF. (Among patients already on dialysis in those centers, AVF
rates increased substantially over the 30 months of observation, from 30.9% to 38.6%,
and there was no association between a county’s wealth or poverty and the rate of
change in AVF use.)
“The community where a treatment center resides may contribute to variations in predialysis
care. This observation provides support for developing ways to improve quality
of care in these poorly performing communities and raises questions as to why poverty
plays a role in pre-dialysis care, when these variations are not seen following the start of
dialysis,” said Dr. McClellan.
The study authors suspect that the knowledge of local primary care physicians might
vary, leading to delays in referrals for AVF placement. Also, poorer communities might
negatively influence opinions, attitudes, and beliefs among individuals with advanced
kidney disease about the utility of early AVF surgery.
The lack of community-to-community variation after patients start dialysis may result
from support provided the Medicare ESRD program. Medicare reimburses the costs of
ESRD care for all individuals eligible for Social Security benefits regardless of other
patient characteristics. In Dr. McClellan’s study, improvement in AVF use among
patients already on dialysis was measured during a national systematic effort to improve
AVF rates through a program called Fistula First.
Study co-authors include Haimanot Wasse, MD, Ann McClellan, PhD, Lance Waller, PhD
(Emory University); James Holt, PhD (Centers for Disease Control and Prevention); and
Jenna Krisher (ESRD Network 6).
Disclosures: The authors reported no financial disclosures.
The article, entitled “Geographic Concentration of Poverty and Arteriovenous Fistula Use
among ESRD Patients,” will appear online at http://jasn.asnjournals.org/ on August 5,
2010, doi 10.1681/ASN.2009121235.
The content of this article does not reflect the views or opinions of The American Society of
Nephrology (ASN). Responsibility for the information and views expressed therein lies entirely
with the author(s). ASN does not offer medical advice. All content in ASN publications is for
informational purposes only, and is not intended to cover all possible uses, directions,
precautions, drug interactions, or adverse effects. This content should not be used during a
medical emergency or for the diagnosis or treatment of any medical condition. Please consult
your doctor or other qualified health care provider if you have any questions about a medical
condition, or before taking any drug, changing your diet or commencing or discontinuing any
course of treatment. Do not ignore or delay obtaining professional medical advice because of
information accessed through ASN. Call 911 or your doctor for all medical emergencies.
Founded in 1966, the American Society of Nephrology (ASN) is the world’s largest professional
society devoted to the study of kidney disease. Comprised of 11,000 physicians and scientists,
ASN continues to promote expert patient care, to advance medical research, and to educate the
renal community. ASN also informs policymakers about issues of importance to kidney doctors
and their patients. ASN funds research, and through its world-renowned meetings and first-class
publications, disseminates information and educational tools that empower physicians.


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