title: A systematic review of patient and health system characteristics associated with late referral in chronic kidney disease.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Nephrology, University of Rochester, Rochester, NY, USA. sankardass@hotmail.com
authors.forename: Sankar D
authors.initials: SD
authors.lastname: Navaneethan
authors.forename: Sarah
authors.initials: S
authors.lastname: Aloudat
authors.forename: Sonal
authors.initials: S
authors.lastname: Singh
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health; D003695:Delivery of Health Care / Q000592:standards* / Q000639:trends; D004522:Educational Status; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D008913:Minority Groups / Q000706:statistics & numerical data; D009398:Nephrology / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data* / Q000639:trends; D006435:Renal Dialysis / Q000592:standards / Q000639:trends*; D018570:Risk Assessment; D012720:Severity of Illness Index; D012959:Socioeconomic Factors; D013997:Time Factors; D014481:United States