title: Are gatekeepers to renal services referring patients equitably?
abstract: OBJECTIVE
  Patients with chronic kidney disease (CKD) benefit from specialist interventions to retard progression of renal failure and prevent cardiovascular events. Certain patient groups have poor access to specialist renal services when dialysis is required. This study used a population-based laboratory database to investigate access to and timeliness of referral to renal specialists relatively early in the course of the disease.
  
  
  METHODS
  All tests for serum creatinine and haemoglobin (Hb) A(1)c in Northern Ireland in a two-year period (2001 and 2002) were retrieved for 345,441 adults. Of these, 16,856 patients had at least one serum creatinine level above 150 micromol/L in 2001 not deemed to be due to acute renal failure (crude prevalence 1.42%). This cohort was followed until the end of 2002 and the differences in the time to referral to a specialist were assessed using Cox's proportional hazards regression.
  
  
  RESULTS
  Diabetic patients, older patients and those living in deprived areas were significantly more likely to have serum creatinine testing, compared with non-diabetic, younger and those living in more affluent areas. Delays in referral to renal specialists for patients with raised serum creatinine levels were significantly shorter among diabetic patients, women, younger individuals, those living in rural areas, those living close to renal centres and those living in deprived areas. Overall, only 19% of diabetic patients and 6% of non-diabetic patients who had CKD had seen a renal specialist within 12 months of their index creatinine test.
  
  
  CONCLUSIONS
  Contrary to other diseases, disadvantaged patients do not seem to be under-investigated for renal disease compared with their more affluent neighbours and are generally referred earlier for specialist assessment. However, the absolute rate of timely specialist assessment is low. Recent changes in referral criteria for CKD will result in more referrals and will have serious resource implications. Opportunities for health gain among patients with declining renal function are being missed, particularly among the old and those living furthest from specialist centres.
authors.affiliation: Department of Epidemiology & Public Health, Queen's University of Belfast, Belfast, UK.
authors.forename: Frank
authors.initials: F
authors.lastname: Kee
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Reaney
authors.forename: Gerard
authors.initials: G
authors.lastname: Savage
authors.forename: Dermot
authors.initials: D
authors.lastname: O'Reilly
authors.forename: Chris
authors.initials: C
authors.lastname: Patterson
authors.forename: Peter
authors.initials: P
authors.lastname: Maxwell
authors.forename: Damian
authors.initials: D
authors.lastname: Fogarty
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007676:Kidney Failure, Chronic / Q000517:prevention & control*; D008297:Male; D008485:Medical Audit; D008511:Medicine; D008875:Middle Aged; D009660:Northern Ireland; D011203:Poverty; D012017:Referral and Consultation; D012935:Social Justice; D013038:Specialization