Kee Frank, Reaney Elizabeth, Savage Gerard, O'Reilly Dermot, Patterson Chris, Maxwell Peter, Fogarty Damian
Department of Epidemiology & Public Health, Queen's University of Belfast, Belfast, UK.
J Health Serv Res Policy. 2007 Jan;12(1):36-41. doi: 10.1258/135581907779497530.
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.
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.
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.
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.
慢性肾脏病（CKD）患者可从延缓肾衰竭进展及预防心血管事件的专科干预措施中获益。某些患者群体在需要透析时难以获得专科肾脏服务。本研究利用基于人群的实验室数据库，调查在疾病进程相对早期转诊至肾脏专科医生的可及性和及时性。
检索了北爱尔兰在两年期间（2001年和2002年）345441名成年人的所有血清肌酐和血红蛋白（Hb）A₁c检测结果。其中，16856名患者在2001年至少有一次血清肌酐水平高于150微摩尔/升，且不被认为是急性肾衰竭所致（粗患病率1.42%）。对该队列进行随访至2002年底，并使用Cox比例风险回归评估转诊至专科医生的时间差异。
与非糖尿病、年轻及生活在较富裕地区的人群相比，糖尿病患者、老年患者及生活在贫困地区的人群进行血清肌酐检测的可能性显著更高。血清肌酐水平升高的患者转诊至肾脏专科医生的延迟时间在糖尿病患者、女性、年轻人、生活在农村地区的人群、居住在肾脏中心附近的人群及生活在贫困地区的人群中显著更短。总体而言，患有CKD的糖尿病患者中只有19%，非糖尿病患者中只有6%在首次肌酐检测后的12个月内看过肾脏专科医生。
与其他疾病不同，与较富裕的邻居相比，弱势患者在肾脏疾病方面似乎未得到充分检查，且通常更早被转诊进行专科评估。然而，及时进行专科评估的绝对比例较低。CKD转诊标准最近的变化将导致更多转诊，这将对资源产生严重影响。肾功能下降患者获得健康改善的机会正在丧失，尤其是老年人和居住在离专科中心最远的人群。
