Prevalence of and factors associated with suboptimal care before initiation of dialysis in the united states

Despite improvements in dialysis care, the mortality of patients with end-s tage renal disease (ESRD) in the United States remains high. Factors that t hus far have received scant attention, but could significantly affect morbi dity and mortality in dialysis patients, are the timing and quality of care before the initiation of dialysis (pre-ESRD). Data from the new version of the Health Care Financing Administration (HCFA) 2728 Form were used to exa mine the prevalence of and factors associated with hypoalbuminemia, severe anemia, and erythropoietin (EPO) use among 155,076 incident chronic dialysi s patients in the United States between April 1, 1995 and June 30, 1997. At initiation of dialysis, the median serum albumin and hematocrit were 3.3 g /dl and 28%, respectively. Sixty percent of patients had a serum albumin be low the lower limit of normal and 51% had a hematocrit <28%. Overall, only 23% had received EPO pre-ESRD. Among patients with hematocrit <28%, only 20 % were receiving EPO, compared to 27% among patients with hematocrit greate r than or equal to 28%. In a multivariate analysis that adjusted for diabet es, functional status, and demographic, socioeconomic, and geographic facto rs, the odds ratios for hypoalbuminemia, hematocrit <28%, and lack of EPO u se were higher for African-Americans, patients with non-private insurance o r no insurance, and patients who were started on hemodialysis. There were a lso significant differences in odds ratios for these outcomes between diffe rent geographic regions in the United States. The high prevalence of pre-ES RD hypoalbuminemia, hematocrit <28%, and lack of EPO use suggests that the quality of pre-ESRD care in the United States is suboptimal. Improvement in pre-ESRD care could potentially improve outcomes among ESRD patients.