Predialysis nephrology care and costs in elderly patients initiating dialysis

Background: Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization. Methods: We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1-3 nephrology visits), moderate- (4-6 visits), and high-intensity (>6 visits) nephrology care during this time period. Results: There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of $103,772, $96,390, $93,336, and $89,961 in total healthcare costs (P < 0.001), respectively. Greater intensity of predialysis nephrology care was associated with lower costs even among patients whose first predialysis nephrology visit was ≤3 months before dialysis initiation. Patients with greater predialysis nephrology care also had lower mortality rates during the year after dialysis initiation (43%, 38%, 28%, and 25%, respectively, P < 0.001). Conclusions: Greater intensity of predialysis nephrology care was associated with fewer hospital days and lower total healthcare costs during the year after dialysis initiation, even though patients survived longer.