title: Patient referral is influenced by dialysis centre structure in the Diamant Alpin Dialysis cohort study.
abstract: BACKGROUND
  Late referral (LR) to the nephrologist of patients with progressing chronic kidney disease (CKD) has numerous deleterious effects and is observed in many countries. The contributing factors associated with LR are controversial and poorly defined. We hypothesized that these factors might be better identified by analysing patients starting dialysis in three distinct European countries within the same area.
  
  
  METHODS
  The referral and progression of kidney failure patterns were analysed with demographic, clinical and biological data in 279 non-selected consecutive patients starting dialysis in eight centres of three adjacent regions in France, Italy and Switzerland.
  
  
  RESULTS
  Early referral (>6 months before the start of dialysis) was seen in 200 patients (71.6%), intermediate referral (1-6 months) in 42 (15.1%) and LR (<1 month) in 37 (13.3%). However inter-centre variations were between 2 and 19% for LR and 6-50% for combined late and intermediate referral. There were no differences at the national levels, but LR was more frequent in the large city centres than in the private or regional structures, with 31 out of 169 (18.3%), two out of 55 (5.4%) and four out of 55 (7.3%), respectively, of their patients (P<0.01). By multivariate analysis, it appears that, besides the presence of an active cancer and the CKD progression rate, the centre structure and the referring physician (primary care physicians and nephrologists are less responsible for LR than other medical specialists) play a significant role in the practice of LR.
  
  
  CONCLUSIONS
  Within a dialysis cohort spread over adjacent regions of three countries, LR has the same global distribution pattern, indicating that different health and social security systems do not play a major role in inducing or preventing this practice. The contributing factors for LR that were identified are the type of the referring physician and the structure of the dialysis unit. Both factors are potential targets for an educational and collaborative approach.
authors.affiliation: CHUV Lausanne, Lausanne, Switzerland. Jean-Pierre.Wauters@insel.ch
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Wauters
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Bosson
authors.forename: Giacomo
authors.initials: G
authors.lastname: Forneris
authors.forename: Cécile
authors.initials: C
authors.lastname: Turc-Baron
authors.forename: Dela
authors.initials: D
authors.lastname: Golshayan
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Paternoster
authors.forename: Guido
authors.initials: G
authors.lastname: Martina
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Hurot
authors.forename: Beat
authors.initials: B
authors.lastname: von Albertini
authors.forename: Michel
authors.initials: M
authors.lastname: Forêt
authors.forename: Daniel
authors.initials: D
authors.lastname: Cordonnier
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Piccoli
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003956:Dialysis / Q000706:statistics & numerical data*; D018450:Disease Progression; D005060:Europe / Q000453:epidemiology; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008875:Middle Aged; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013997:Time Factors