Abstract
BackgroundMultiple factors influence timing of dialysis initiation. The impact of supply of nephrology workforce on timing and incidence of dialysis initiation is not well known.MethodsWe determined the number of pediatric and adult nephrologists in each state using data from the American Medical Association and American Boards of Internal Medicine and Pediatrics. We ascertained state population data from the 2010 US Census. United States Renal Data System (USRDS) data were used to determine estimated glomerular filtration rate (eGFR) at dialysis initiation and dialysis incidence for adults (≥18 years) in 2008 and children (<18 years) in 2007–2009 by state.ResultsAcross all states, there were a median of 3.0 (IQR 2.3 to 3.4) adult nephrologists per 100,000 adults and 0.5 (IQR 0.2 to 0.9) pediatric nephrologists per 100,000 children. The median eGFR at start of dialysis was 9.8 mL/min/1.73 m2 (IQR 7.1-13.1) in adults and 8.5 mL/min/1.73 m2 (IQR 6.2-11.4) in children. Neither the number of adult (Spearman r of 0.02 [95% CI −0.26-0.30], p = 0.88) nor pediatric (Spearman r of −0.13 [95% -0.39-0.15], p = 0.38) nephrologists per state population was associated with mean eGFR across states. The number of nephrologists per state population was associated with incident dialysis cases per state population in adults (Spearman r of 0.50 [95% CI 0.26-0.68], p = 0.0002), but not in children (Spearman r of −0.06 [95% CI −0.33-0.22], p = 0.67). In linear regression models, the association between nephrologists per state population and incident dialysis cases per state population remained statistically significant (p = 0.006) after adjustment for provider characteristics.ConclusionsNephrology workforce supply is aligned with demand but does not appear to be associated with timing of dialysis initiation.
Highlights
Multiple factors influence timing of dialysis initiation
In a recent survey of European nephrologists, opinions regarding the optimal timing of dialysis initiation differed based on whether respondents were from for-profit versus nonprofit centers; those from for-profit organizations were more likely to favor early dialysis initiation [11]
We confirmed the size and location of the current nephrology workforce derived from the American Medical Association (AMA)-Physician Professional Data (PPD) file using most recent data available at time of study performance from the American Boards of Internal Medicine (ABIM) and Pediatrics (ABP), which were updated as of 2/17/2011 and 12/31/2010, respectively
Summary
Determination of state level variation in nephrology workforce To estimate the size and location of the current nephrology workforce, we used deidentified data from the 2008 American Medical Association (AMA) Physician Professional Data (PPD) Statistical Research file, which contains data on the primary specialty, demographic characteristics, type of practice (private versus academic versus research), and location of physicians in the US [16,17]. We confirmed the size and location of the current nephrology workforce derived from the AMA-PPD file using most recent data available at time of study performance from the American Boards of Internal Medicine (ABIM) and Pediatrics (ABP), which were updated as of 2/17/2011 and 12/31/2010, respectively. Both organizations publish the total number of board-certified adult and pediatric nephrologists annually and use updated candidate addresses on file to assign their locations by state. The Committee on Human Research of the University of California San Francisco consider the scope of this work to be exempt human subjects research
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