Journal of General Internal Medicine

, Volume 23, Issue 3, pp 329–336

Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda

  • Kellie Hunter Campbell
  • William Dale
  • Nicole Stankus
  • Greg A. Sachs
Health Policy

Abstract

Background

Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.

Objective

This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD.

Results

While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD.

Conclusions

More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.

KEY WORDS

chronic kidney disease decision making older adults 

References

  1. 1.
    Baylis C. Changes in renal hemodynamics and structure in the aging kidney; sexual dimorphism and the nitric oxide system. Exp Gerontol. 2005;40(4):271–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Shlipak MG, Fried LF, Crump C, et al. Cardiovascular disease risk status in elderly persons with renal insufficiency. Kidney Int. 2002;62(3):997–1004.PubMedCrossRefGoogle Scholar
  3. 3.
    Coresh J, Byrd-Holt D, Astor BC, et al. Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000. J Am Soc Nephrol. 2005;16(1):180–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038–47.PubMedCrossRefGoogle Scholar
  5. 5.
    National Institutes of Health, National Institutes of Diabetes and Digestive Disorders and Kidney Diseases. USRDS 2005 Annual Data Report: Atlas of End-Stage Renal Disease. 2005.Google Scholar
  6. 6.
    National Kidney Foundation, Inc. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. 2002.Google Scholar
  7. 7.
    Stack AG. Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis. 2003;41(2)310–18.PubMedCrossRefGoogle Scholar
  8. 8.
    Jungers P, Zingraff J, Page B, Albouze G, Hannedouche T, Man NK. Detrimental effects of late referral in patients with chronic renal failure: a case-control study. Kidney Int Suppl. 1993;41:S170–3.PubMedGoogle Scholar
  9. 9.
    Fink J, Blahut S, Reddy M, Light P. Use of erythropoietin before the initiation of dialysis and its impact on mortality. Am J Kidney Dis. 2001;37(2):348–55.PubMedCrossRefGoogle Scholar
  10. 10.
    Astor BC, Eustace JA, Powe N, et al. Timing of nephrologist referral and arteriovenous access use: the CHOICE Study. Am J Kidney Dis. 2001;38(3):494–501.PubMedCrossRefGoogle Scholar
  11. 11.
    Churchill DN, Blake PG, Jindal KK, Toffelmire EB, Goldstein MB. Clinical practice guidelines for initiation of dialysis. Canadian Society of Nephrology. J Am Soc Nephrol. 1999;10(Suppl 13):S289–91.PubMedGoogle Scholar
  12. 12.
    Krediet RT. The European Best Practice Guideline Working Group on Peritoneal Dialysis. The initiation of dialysis. Nephrol Dial Transplant. 2005;20(Suppl 9):ix3–7.PubMedGoogle Scholar
  13. 13.
    Piccoli GB, Grassi G, Mezza E, et al. Early referral of type 2 diabetic patients: are we ready for the assault? Nephrol Dial Transplant. 2002;17(7):1241–1247.PubMedCrossRefGoogle Scholar
  14. 14.
    Boulware LE, Troll MU, Jaar BG, Myers DI, Powe NR. Identification and referral of patients with progressive CKD: a national study. Am J Kidney Dis. 2006;48(2):192–204.PubMedCrossRefGoogle Scholar
  15. 15.
    Fox CH, Brooks A, Zayas LE, McClellan W, Murray B. Primary care physicians’ knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study. J Am Board Fam Med. 2006;19(1):54–61.PubMedGoogle Scholar
  16. 16.
    Lea JP, McClellan WM, Melcher C, Gladstone E, Hostetter T. CKD risk factors reported by primary care physicians: do guidelines make a difference? Am J Kidney Dis. 2006;47(1):72–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Montgomery AJ, McGee HM, Shannon W, Donohoe J. Factors influencing general practitioner referral of patients developing end-stage renal failure: a standardised case-analysis study. BMC Health Serv Res. 2006;6:114.PubMedCrossRefGoogle Scholar
  18. 18.
    Mendelssohn DC, Kua BT, Singer PA. Referral for dialysis in Ontario. Arch Intern Med. 1995;155(22):2473–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Campbell JD, Ewigman B, Hosokawa M, Van Stone JC. The timing of referral of patients with end-stage renal disease. Dial Transplant. 1989;18(12):660–86.Google Scholar
  20. 20.
    Parry RG, Crowe A, Stevens JM, Mason JC, Roderick P. Referral of elderly patients with severe renal failure: questionnaire survey of physicians. BMJ. 1996;313(7055):466.PubMedGoogle Scholar
  21. 21.
    Sekkarie MA, Moss AH. Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status. Am J Kidney Dis. 1998;31(3):464–72.PubMedCrossRefGoogle Scholar
  22. 22.
    Clement , Chevalet P, Rodat O, Ould-Aoudia V, Berger M. Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France. Nephrol Dial Transplant. 2005;20(11):2446–52.PubMedCrossRefGoogle Scholar
  23. 23.
    Kinchen KS, Sadler J, Fink N, et al. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med. 2002;137(6):479–86.PubMedGoogle Scholar
  24. 24.
    McKenzie JK, Moss AH, Feest TG, Stocking CB, Siegler M. Dialysis decision making in Canada, the United Kingdom, and the United States. Am J Kidney Dis. 1998;31(1):12–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Sekkarie M, Cosma M, Mendelssohn D. Nonreferral and nonacceptance to dialysis by primary care physicians and nephrologists in Canada and the United States. Am J Kidney Dis. 2001;38(1):36–41.PubMedCrossRefGoogle Scholar
  26. 26.
    Wilson R, Godwin M, Seguin R, et al. End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain. Am J Kidney Dis. 2001;38(1):42–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Lambie M, Rayner HC, Bragg-Gresham JL, et al. Starting and withdrawing haemodialysis—associations between nephrologists’ opinions, patient characteristics and practice patterns (data from the Dialysis Outcomes and Practice Patterns Study). Nephrol Dial Transplant. 2006;21(10):2814–20.PubMedCrossRefGoogle Scholar
  28. 28.
    Kjellstrand CM. Age, sex, and race inequality in renal transplantation. Arch Intern Med. 1988;148(6):1305–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Kjellstrand CM, Logan GM. Racial, sexual and age inequalities in chronic dialysis. Nephron. 1987;45(4):257–63.PubMedCrossRefGoogle Scholar
  30. 30.
    Joly D, Anglicheau D, Alberti C, et al. Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes. J Am Soc Nephrol. 2003;14(4):1012–21.PubMedCrossRefGoogle Scholar
  31. 31.
    Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science. 1973;182(117):1102–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA. 1992;267(12):1624–30.PubMedCrossRefGoogle Scholar
  33. 33.
    Schneeweiss , Ellsbury K, Hart LG, Geyman JP. The economic impact and multiplier effect of a family practice clinic on an academic medical center. JAMA. 1989;262(3):370–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106–12.PubMedCrossRefGoogle Scholar
  35. 35.
    Watson E, Austoker J, Lucassen A. A study of GP referrals to a family cancer clinic for breast/ovarian cancer. Fam Pract. 2001;18(2):131–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Donohoe MT, Kravitz RL, Wheeler DB, Chandra , Chen A, Humphries N. Reasons for outpatient referrals from generalists to specialists. J Gen Intern Med. 1999;14(5):281–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Ashworth M, Godfrey E, Harvey K, Darbishire L. Perceptions of psychological content in the GP consultation—the role of practice, personal and prescribing attributes. Fam Pract. 2003;20(4):373–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Sigel P, Leiper R. GP views of their management and referral of psychological problems: a qualitative study. Psychol Psychother. 2004;77(Pt 3):279–95.PubMedCrossRefGoogle Scholar
  39. 39.
    Forrest CB, Nutting PA, von Schrader S, Rohde C, Starfield B. Primary care physician specialty referral decision making: patient, physician, and health care system determinants. Med Decis Mak. 2006;26(1):76–85.CrossRefGoogle Scholar
  40. 40.
    Gerrity MS, Earp JA, DeVellis RF, Light DW. Uncertainty and professional work: perceptions of physicians in clinical practice. Am J Soc. 1992;97(4):1022–51.CrossRefGoogle Scholar
  41. 41.
    Langley G, Minkin S, Till JE. Regional variation in nonmedical factors affecting family physicians’ decisions about referral for consultation. CMAJ. 1997;157(3):265–72.PubMedGoogle Scholar
  42. 42.
    Kinchen KS, Cooper LA, Levine D, Wang NY, Powe NR. Referral of patients to specialists: factors affecting choice of specialist by primary care physicians. Ann Fam Med. 2004;2(3):245–52.PubMedCrossRefGoogle Scholar
  43. 43.
    Kinchen KS, Cooper LA, Wang NY, Levine D, Powe NR. The impact of international medical graduate status on primary care physicians’ choice of specialist. Med Care. 2004;42(8):747–55.PubMedCrossRefGoogle Scholar
  44. 44.
    O’Neill L, Kuder J. Explaining variation in physician practice patterns and their propensities to recommend services. Med Care Res Rev. 2005;62(3):339–57.PubMedCrossRefGoogle Scholar
  45. 45.
    Iverson GD, Coleridge ST, Fulda KG, Licciardone JC. What factors influence a family physician’s decision to refer a patient to a specialist? Rural Remote Health. 2005;5(3):413.PubMedGoogle Scholar
  46. 46.
    McKinlay JB, Lin T, Freund K, Moskowitz M. The unexpected influence of physician attributes on clinical decisions: results of an experiment. J Health Soc Behav. 2002;43(1):92–106.PubMedCrossRefGoogle Scholar
  47. 47.
    Clemence ML, Seamark DA. GP referral for physiotherapy to musculoskeletal conditions—a qualitative study. Fam Pract. 2003;20(5):578–82.PubMedCrossRefGoogle Scholar
  48. 48.
    Forrest CB, Nutting PA, Starfield B, von Schrader S. Family physicians’ referral decisions: results from the ASPN referral study. J Fam Pract. 2002;51(3):215–22.PubMedGoogle Scholar
  49. 49.
    Ruston A, Ruston Argau, Ruston ACfHRaESo, Health and Social Care UoGGBS, Site AHRELUKSEUG, ra24@gre.ac.uk. Risk, anxiety and defensive action: General practitioner’s referral decisions for women presenting with breast problems. 2004. Health, Risk Soc. 6(1):25–38.Google Scholar
  50. 50.
    Starfield B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract. 2002;15(6):473–80.PubMedGoogle Scholar
  51. 51.
    Flynn D, van Schaik P, van Wersch A, Douglass A, Cann P. Non-Medical Influences Upon Medical Decision-Making and Referral Behavior. Westport, CT: Praeger; 2003.Google Scholar
  52. 52.
    Feltovich PJ, Coulson RL, Spiro RJ, Dawson-Saunders BK. Knowledge Application and Transfer for Complex Tasks in Ill-Structured Domains: Implications for Instruction and Testing in Biomedicine. New York: Springer; 1992.Google Scholar
  53. 53.
    van Schaik P, Flynn D, van Wersch A, et al. Influence of illness script components and medical practice on medical decision making. J Exp Psychol Applied. 2005;11(3):187–99.CrossRefGoogle Scholar
  54. 54.
    Whitney SN, McCullough LB. Physicians’ silent decisions: because patient autonomy does not always come first. Am J Bioeth. 2007;7(7):33–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Mazur DJ, Hickam DH, Mazur MD, Mazur MD. The role of doctor’s opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures? Health Expect. 2005;8(2):97–102.PubMedCrossRefGoogle Scholar
  56. 56.
    Gurmankin AD, Baron J, Hershey JC, Ubel PA. The role of physicians’ recommendations in medical treatment decisions. Med Decis Mak. 2002;22(3):262–71.CrossRefGoogle Scholar
  57. 57.
    Rosenstock IM, Strecher VJ, Champion VL. The Health Belief Model and Health Behavior: Handbook of Health Behavior Research Personal and Social Determinants. New York: Plenum; 1997.Google Scholar
  58. 58.
    Prochaska JO, Norcross JC. Systems of Psychotherapy: A Transtheoretical Analysis. Belmont, CA: Wadsworth; 1979.Google Scholar
  59. 59.
    Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313–20.PubMedCrossRefGoogle Scholar
  60. 60.
    Kjellgren KI, Svensson S, Ahlner J, Saljo R. Antihypertensive treatment and patient autonomy—the follow-up appointment as a resource for care. Patient Educ Couns. 2000;40(1):39–49.PubMedCrossRefGoogle Scholar
  61. 61.
    Gotler RS, Flocke SA, Goodwin MA, Zyzanski SJ, Murray TH, Stange KC. Facilitating participatory decision-making: what happens in real-world community practice? Med Care. 2000;38(12):1200–9.PubMedCrossRefGoogle Scholar
  62. 62.
    Mort EA, Edwards JN, Emmons DW, Convery K, Blumenthal D. Physician response to patient insurance status in ambulatory care clinical decision-making. Implications for quality of care. Med Care. 1996;34(8):783–97.PubMedCrossRefGoogle Scholar
  63. 63.
    Ryynanen OP, Myllykangas M, Kinnunen J, Takala J. Doctors’ willingness to refer elderly patients for elective surgery. Fam Pract. 1997;14(3):216–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Kellie Hunter Campbell
    • 1
  • William Dale
    • 1
  • Nicole Stankus
    • 2
  • Greg A. Sachs
    • 1
  1. 1.Section of GeriatricsUniversity of ChicagoChicagoUSA
  2. 2.Section of NephrologyUniversity of ChicagoChicagoUSA

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