title: Referral patterns of primary care physicians for chronic kidney disease in general population and geriatric patients.
abstract: BACKGROUND
  Late referral of patients with chronic kidney disease (CKD) by primary care physicians (PCPs) is associated with poor outcomes. We sought to assess factors influencing PCPs referral patterns in the general population and in geriatric patients, and compared their perceptions to the referral patterns.
  
  
  METHODS
  We retrospectively reviewed 268 patients with Stage 3 CKD (early referral) and 280 with Stage 4 CKD (appropriate referral) seen in renal clinic and compared them to 268 randomly selected non-referred Stage 4 CKD patients from primary care physicians office records. We also surveyed 400 regional PCPs on factors influencing their referral for CKD.
  
  
  RESULTS
  Non-referred patients were significantly (p < 0.05) more likely to be over 65 years (OR: 3.5; 95% CI: 2.3 - 5.2), females (OR: 1.4; 95% CI: 1.0 - 2.0) and of non-white race (OR: 2.6; 95% CI: 1.5 - 4.5) after adjusting for relevant confounding variables. Charlson comorbidity index greater than 4 was associated with non-referral when the non-referral group was compared to the early referral group. Among geriatric patients, women and a higher comorbidity index were associated with non-referral. 25% of PCPs completed the survey and 62% PCPs were unfamiliar with K/DOQI referral guidelines. Age > 75 years, limited life expectancy, patient noncompliance or refusal to consider dialysis influenced PCPs decision to refer.
  
  
  CONCLUSIONS
  Our study shows that elderly women, minorities and patients with multiple comorbidities are at risk for non-referral for CKD care. Educating PCPs on the appropriate referral of CKD patients, especially those at risk for late or non-referral to a nephrologist is warranted, as are trials assessing different educational strategies.
authors.affiliation: Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44122, USA. navanes@ccf.org
authors.forename: S D
authors.initials: SD
authors.lastname: Navaneethan
authors.forename: P
authors.initials: P
authors.lastname: Kandula
authors.forename: V
authors.initials: V
authors.lastname: Jeevanantham
authors.forename: J V
authors.initials: JV
authors.lastname: Nally
authors.forename: S E
authors.initials: SE
authors.lastname: Liebman
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D005260:Female; D019983:Guideline Adherence; D019538:Health Care Surveys; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010821:Physicians, Family; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012017:Referral and Consultation; D006435:Renal Dialysis; D012189:Retrospective Studies; D012737:Sex Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome