Navaneethan S D, Kandula P, Jeevanantham V, Nally J V, Liebman S E
Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44122, USA.
Clin Nephrol. 2010 Apr;73(4):260-7. doi: 10.5414/cnp73260.
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.
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.
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.
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.
基层医疗医生（PCP）对慢性肾脏病（CKD）患者的延迟转诊与不良预后相关。我们试图评估影响普通人群和老年患者中基层医疗医生转诊模式的因素，并将他们的看法与转诊模式进行比较。
我们回顾性分析了在肾脏科就诊的268例3期CKD患者（早期转诊）和280例4期CKD患者（适当转诊），并将他们与从基层医疗医生办公室记录中随机选择的268例未转诊的4期CKD患者进行比较。我们还就影响他们对CKD患者转诊的因素对400名地区基层医疗医生进行了调查。
在对相关混杂变量进行调整后，未转诊患者更有可能（p < 0.05）年龄超过65岁（比值比：3.5；95%置信区间：2.3 - 5.2）、为女性（比值比：1.4；95%置信区间：1.0 - 2.0）以及非白人种族（比值比：2.6；95%置信区间：1.5 - 4.5）。当将未转诊组与早期转诊组进行比较时，Charlson合并症指数大于4与未转诊相关。在老年患者中，女性和较高的合并症指数与未转诊相关。25%的基层医疗医生完成了调查，62%的基层医疗医生不熟悉K/DOQI转诊指南。年龄>75岁、预期寿命有限、患者不依从或拒绝考虑透析影响了基层医疗医生的转诊决定。
我们的研究表明，老年女性、少数族裔和患有多种合并症的患者有未被转诊接受CKD治疗的风险。有必要对基层医疗医生进行关于CKD患者适当转诊的教育，尤其是那些有延迟或未被转诊至肾病专家风险的患者，评估不同教育策略的试验也同样有必要。
