Factors influencing general practitioner referral of patients developing end-stage renal failure: a standardised case-analysis study.
BACKGROUND
To understand why treatment referral rates for ESRF are lower in Ireland than in other European countries, an investigation of factors influencing general practitioner referral of patients developing ESRF was conducted.


METHODS
Randomly selected general practitioners (N = 51) were interviewed using 32 standardised written patient scenarios to elicit referral strategies.


METHODS
General practitioner referral levels and thresholds for patients developing end-stage renal disease; referral routes (nephrologist vs other physicians); influence of patient age, marital status and co-morbidity on referral.


RESULTS
Referral levels varied widely with the full range of cases (0-32; median = 15) referred by different doctors after consideration of first laboratory results. Less than half (44%) of cases were referred to a nephrologist. Patient age (40 vs 70 years), marital status, co-morbidity (none vs rheumatoid arthritis) and general practitioner prior specialist renal training (yes or no) did not influence referral rates. Many patients were not referred to a specialist at creatinine levels of 129 micromol/l (47% not referred) or 250 micromol/l (45%). While all patients were referred at higher levels (350 and 480 micromol/l), referral to a nephrologist decreased in likelihood as scenarios became more complex; 28% at 129 micromol/l creatinine; 28% at 250 micromol/l; 18% at 350 micromol/l and 14% at 480 micromol/l. Referral levels and routes were not influenced by general practitioner age, sex or practice location. Most general practitioners had little current contact with chronic renal patients (mean number in practice = 0.7, s.d. = 1.3).


CONCLUSIONS
The very divergent management patterns identified highlight the need for guidance to general practitioners on appropriate management of this serious condition.
Montgomery
Anthony J
AJ
Department of Psychology, Royal College of Surgeons in Ireland-Medical University of Bahrain, PO Box 15503, Manama, Bahrain. amontgomery@rcsi-mub.com
McGee
Hannah M
HM
Shannon
William
W
Donohoe
John
J
D000367:Age Factors; D003404:Creatinine / Q000032:analysis; D003657:Decision Making; D005163:Factor Analysis, Statistical; D005194:Family Practice / Q000193:education / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D007494:Ireland; D007676:Kidney Failure, Chronic / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D017533:Marital Status; D008511:Medicine; D008875:Middle Aged; D009398:Nephrology / Q000193:education; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000706:statistics & numerical data; D013038:Specialization; D011795:Surveys and Questionnaires; D014572:Urology / Q000193:education
D003404:Creatinine