OBJECTIVE: Early care provided by nephrologists before initiating dialysis may improve treatment outcomes for patients who later progress to end-stage renal disease (ESRD) and start hemodialysis. The objective is to identify factors influencing early nephrology care, defined as visiting a nephrologist from 4 to 12 months prior to hemodialysis initiation among elderly ESRD patients. METHODS: The study population consists of patients initiating hemodialysis in the years 1996-1999, aged 67+ years and having Medicare Part B coverage in the fee-for-service system in the 2nd year prior to dialysis initiation. Patients' characteristics were obtained from Centers for Medicare & Medicaid Services form 2728 files. Comorbidities and hospital utilization were generated from Medicare Part A and/or Part B claims. Physician visits including early nephrology care and access to non-nephrologist physicians and nephrologists practicing in a local area, defined as an area 30 miles within a patient's residence ZIP code, were computed with Medicare Part B physician/supplier files and US 2000 Census data. RESULTS: About 33.79% of 91,189 elderly patients received early nephrology care before starting hemodialysis. Logistic regressions indicated that patients who were male, had hypertension, anemia, more hospital admissions in the year before initiating dialysis, lived in an area with more nephrologists per 1,000 prevalent elderly ESRD patients were more likely to obtain early nephrology care. Patients older than 76 years, having diabetes, living in an area with more non-nephrologist physicians per 10,000 population had a lower likelihood of getting early nephrology care. Patients residing in areas 12 miles or more away from the nearest nephrologist had a smaller odds ratio of receiving early nephrology care compared to patients living in an area less than 4 miles away. CONCLUSIONS: Elderly ESRD patients' characteristics and access to local non-nephrologist physicians and nephrologists affect the use of early nephrology care prior to hemodialysis initiation.