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.
References
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.
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.
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.
Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298(17):2038–47.
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.
National Kidney Foundation, Inc. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. 2002.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Mendelssohn DC, Kua BT, Singer PA. Referral for dialysis in Ontario. Arch Intern Med. 1995;155(22):2473–8.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Kjellstrand CM. Age, sex, and race inequality in renal transplantation. Arch Intern Med. 1988;148(6):1305–9.
Kjellstrand CM, Logan GM. Racial, sexual and age inequalities in chronic dialysis. Nephron. 1987;45(4):257–63.
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.
Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science. 1973;182(117):1102–8.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Clemence ML, Seamark DA. GP referral for physiotherapy to musculoskeletal conditions—a qualitative study. Fam Pract. 2003;20(5):578–82.
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.
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.
Starfield B, Forrest CB, Nutting PA, von Schrader S. Variability in physician referral decisions. J Am Board Fam Pract. 2002;15(6):473–80.
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.
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.
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.
Whitney SN, McCullough LB. Physicians’ silent decisions: because patient autonomy does not always come first. Am J Bioeth. 2007;7(7):33–8.
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.
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.
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.
Prochaska JO, Norcross JC. Systems of Psychotherapy: A Transtheoretical Analysis. Belmont, CA: Wadsworth; 1979.
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.
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.
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.
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.
Ryynanen OP, Myllykangas M, Kinnunen J, Takala J. Doctors’ willingness to refer elderly patients for elective surgery. Fam Pract. 1997;14(3):216–9.
Acknowledgment
The funding source for this work is the John A. Hartford Foundation Center of Excellence in Geriatrics at the University of Chicago.
Conflicts of Interest
None disclosed.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Campbell, K.H., Dale, W., Stankus, N. et al. Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda. J GEN INTERN MED 23, 329–336 (2008). https://doi.org/10.1007/s11606-007-0492-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-007-0492-x