A Systematic Review Of Patient And Health System Characteristics Associated With Late Referral In Chronic Kidney Disease

Sankar D Navaneethan; Sarah Aloudat; Sonal Singh

Disclosures

BMC Nephrology 

In This Article

Abstract and Background

Background: To identify patient and health system characteristics associated with late referral of patients with chronic kidney disease to nephrologists.
Methods: MEDLINE, CENTRAL, and CINAHL were searched using the appropriate MESH terms in March 2007. Two reviewers individually and in duplicate reviewed the abstracts of 256 articles and selected 18 observational studies for inclusion. The reasons for late referral were categorized into patient or health system characteristics. Data extraction and content appraisal were done using a prespecified protocol.
Results: Older age, the existence of multiple comorbidities, race other than Caucasian, lack of insurance, lower socioeconomic status and educational levels were patient characteristics associated with late referral of patients with chronic kidney disease. Lack of referring physician knowledge about the appropriate timing of referral, absence of communication between referring physicians and nephrologists, and dialysis care delivered at tertiary medical centers were health system characteristics associated with late referral of patients with chronic kidney disease. Most studies identified multiple factors associated with late referral, although the relative importance and the combined effect of these factors were not systematically evaluated.
Conclusion: A combination of patient and health system characteristics is associated with late referral of patients with chronic kidney disease. Overall, being older, belonging to a minority group, being less educated, being uninsured, suffering from multiple comorbidities, and the lack of communication between primary care physicians and nephrologists contribute to late referral of patients with chronic kidney disease. Both primary care physicians and nephrologists need to engage in multisectoral collaborative efforts that ensure patient education and enhance physician awareness to improve the care of patients with chronic kidney disease.

Chronic kidney disease is an emerging public health problem. A recent study reported that nearly 26 million Americans suffer from Chronic Kidney Disease (CKD).[1] Future projections for the US population estimate more than 700,000 prevalent cases of End Stage Renal Disease (ESRD) by the year 2015.[2] Observational studies and their meta-analysis have shown that late referral of patients with CKD to nephrologists is associated with poor clinical outcomes.[3,4,5,6,7] Longer pre-dialysis care by nephrologists may result in reduction in rates of hospitalization and mortality.[3,4,5,6,7]

There is no universally accepted definition of 'Late referral' of patients with CKD. Several inconsistent criteria including the number of months prior to the initiation of dialysis(1 month, 3 months or 6 months), or the stage of CKD have been used to define late referral of patients with CKD. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiatives (K-DOQI) guidelines recommend that patients with CKD be referred to nephrologists when the glomerular filtration rates (GFR) fall below 30 ml/min (Stage 4 CKD), and earlier if possible (evidence category-opinion).[8] Similar guidelines have been issued by other agencies.[9,10,11] This inconsistency in the definition of late referral is attributable to changing practice patterns among physician's, changes in the definition of CKD, and increasing awareness among physicians and patients. The optimal timing of referral varies depending on physicians' characteristics and preferences, practice setting, the comfort level of the treating physicians and the availability of nephrologists.

The development of interventions to address late referral of patients with CKD is hampered by the lack of a comprehensive understanding of the factors responsible for late referral. Despite the existence of these guidelines, nearly 15–80% of patients who start dialysis are referred late.[12,13,14] Retrospective studies and narrative reviews have identified several individual factors, such as ethnicity and insurance status that contribute to late referral.[15,16,17,18,19,20] Late referral now documented for over 15 years is increasing as reported in recent studies.

Our objectives were to systematically review the evidence on patient and health system characteristics associated with late referral of patients with CKD. In order to be comprehensive in our approach, we aimed to ascertain the factors associated with late referral as defined in earlier studies (<1 month prior to initiation of dialysis to <6 months of initiation of dialysis), as well as the definition of late referral outlined in the current National Kidney Foundation guideline recommendations (patients with GFR below 30 ml/min or in Stage 4 CKD).

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