title: Interventions to reduce late referrals to nephrologists.
abstract: BACKGROUND
  Despite the adverse health outcomes with late nephrology referral for patients with chronic kidney disease (CKD), little is known about the underlying mechanisms and reasons for late referral patterns.
  
  
  METHODS
  We conducted a Medline search for peer-reviewed articles focused on nephrology referral among adults with CKD. We critically reviewed this literature in regard to late nephrology referral, highlighted its shortcomings, and provided a theoretically based framework for future research.
  
  
  RESULTS
  Late referral has been attributed to three key types of factors: primary care provider (PCP), patient, and healthcare system factors. Limited empirical research has pointed to knowledge deficits, perceptions, and preferences by PCPs as well as to knowledge deficits, psychological concerns, and economic concerns by patients. The existing literature is severely limited by retrospective designs, closed-ended surveys, and the absence of a theoretically driven conceptual framework to fully evaluate root causes of this ongoing problem. Social Cognitive Theory may be a particularly well-suited conceptual model for late nephrology referral because important PCP and patient factors correspond to key constructs of this theory.
  
  
  CONCLUSIONS
  Future research is needed to delineate pathways underlying reasons for PCPs' late referral patterns and CKD patients' referral nonadherence. Interventions are urgently needed to reduce late referrals and improve the health of patients with CKD.
authors.affiliation: Center for Management of Complex Chronic Care, VA Hospital, Hines, Ill., USA. fischerm@uic.edu
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Fischer
authors.forename: Shubhada N
authors.initials: SN
authors.lastname: Ahya
authors.forename: Elisa J
authors.initials: EJ
authors.lastname: Gordon
mesh_terms: D002170:Canada; D003071:Cognition; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007674:Kidney Diseases / Q000628:therapy*; D007676:Kidney Failure, Chronic / Q000628:therapy; D016239:MEDLINE; D008484:Medicaid; D009398:Nephrology / Q000379:methods*; D010349:Patient Compliance; D011320:Primary Health Care / Q000458:organization & administration; D012017:Referral and Consultation; D013997:Time Factors; D014481:United States