Patient Care Gaps Prior to Maintenance Dialysis Initiation: A Population-Based Retrospective Study
Bibliographic record
Abstract
Background: Guidelines in Ontario, Canada, recommend timely referral for multidisciplinary kidney care to facilitate planned dialysis initiation. Many patients do not receive recommended multidisciplinary kidney care prior to dialysis. Objective: To better understand why this gap in pre-dialysis care exists, we conducted a study to describe the pathways by which patients initiate maintenance dialysis. Design: A retrospective cohort study. Setting: Population-based, using health care administrative databases from Ontario, Canada. Patients: Adults initiating maintenance dialysis from April 2016 to March 2019. Measurements and methods: Patients were grouped based on whether they received recommended multidisciplinary kidney care prior to dialysis initiation (at least 1 year of care with at least 2 visits). For those who did not receive recommended care, we grouped patients as having no identified care gap or into the following groups: (1) lack of timely chronic kidney disease (CKD) screening, (2) late nephrology referral (<1 year), or (3) late or no referral for multidisciplinary kidney care among patients followed by a nephrologist for at least 1 year. Results: A total of 9216 patients were included with a mean (standard deviation) age of 66 (15) years, and 61.5% were male. Of the total, 896 (9.7%) patients died, 7671 (83.2%) remained on dialysis at 90 days, and 649 (7.0%) had stopped dialysis due to kidney function recovery within 90 days. Of the 9216 patients, 5434 (59%) had not received recommended multidisciplinary kidney care. Among those without recommended care, there were 2251 (41.4%) patients with no identified care gaps, 1351 (24.9%) patients with a lack of timely CKD screening, 359 (6.6%) patients with late nephrology referral, and 1473 (27.1%) patients with late or no referral for multidisciplinary kidney care. Limitations: We could not determine if patients were referred but declined multidisciplinary kidney care. Conclusions: More than half of patients had not received recommended multidisciplinary kidney care. Many patients experienced an acute decline in kidney function, which may not be preventable, but in others, there were missed opportunities for CKD screening or early referral to nephrology, or at the level of nephrology practice for early referral for multidisciplinary care. This work could be used to inform policies aimed at improving increased uptake of multidisciplinary kidney care prior to dialysis.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.004 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".