Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making

BMC Nephrology

Research Article

Sandy G Smith¹  Marshall H Chin²  Joshua Hemmerich³  William Dale³  Kellie H Campbell³  Nicole Stankus⁴  Chester Fox⁵  James W Mold⁶  Ann M O'Hare⁷ 

[1] University of Chicago, Pritzker School of Medicine, 924 East 57 th Street, BSLC 013A, 60637, Chicago, Illinois, USA;University of Chicago, Section of General Internal Medicine, 5841 South Maryland Avenue, MC 200760637, Chicago, Illinois, USA;University of Chicago, Section of Geriatrics and Palliative Medicine, 5841 South Maryland Avenue, MC 6098, 60637, Chicago, Illinois, USA;University of Chicago, Section of Nephrology, 5841 South Maryland Avenue, MC 5000, 60637, Chicago, Illinois, USA;University of New York at Buffalo, Department of Family Medicine, 462 Grider Street, 14215, Buffalo, New York, USA;University of Oklahoma, Department of Family Medicine, 900 North East 10 th Street, 73104, Oklahoma City, Oklahoma, USA;VA/Puget Sound Medical Center, 1660 South Columbian Way, 98108, Seattle, Washington, USA;

关键词: Chronic Kidney Disease;    Risk Aversion;    Chronic Kidney Disease Patient;    Dialysis Initiation;    Advanced Chronic Kidney Disease;   

DOI  :  10.1186/1471-2369-12-47

 received in 2011-03-29, accepted in 2011-09-26,  发布年份 2011

来源: Springer

【 摘 要 】

BackgroundAlthough chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.MethodsWe administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.ResultsMore than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).ConclusionsIn this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

【 授权许可】

CC BY   
© Campbell et al; licensee BioMed Central Ltd. 2011