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Open Access Research article

Effect of primary care physicians' use of estimated glomerular filtration rate on the timing of their subspecialty referral decisions

Raquel C Greer1*, Neil R Powe3, Bernard G Jaar2456, Misty U Troll14 and L Ebony Boulware124

Author Affiliations

1 Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

2 Welch Center for Prevention, Epidemiology and Clinical Research, Baltimore, Maryland, USA

3 Department of Medicine, University of California San Francisco, San Francisco, California, USA

4 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

5 Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

6 Nephrology Center of Maryland, Baltimore, Maryland USA

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BMC Nephrology 2011, 12:1  doi:10.1186/1471-2369-12-1

Published: 14 January 2011

Abstract

Background

Primary care providers' suboptimal recognition of the severity of chronic kidney disease (CKD) may contribute to untimely referrals of patients with CKD to subspecialty care. It is unknown whether U.S. primary care physicians' use of estimated glomerular filtration rate (eGFR) rather than serum creatinine to estimate CKD severity could improve the timeliness of their subspecialty referral decisions.

Methods

We conducted a cross-sectional study of 154 United States primary care physicians to assess the effect of use of eGFR (versus creatinine) on the timing of their subspecialty referrals. Primary care physicians completed a questionnaire featuring questions regarding a hypothetical White or African American patient with progressing CKD. We asked primary care physicians to identify the serum creatinine and eGFR levels at which they would recommend patients like the hypothetical patient be referred for subspecialty evaluation. We assessed significant improvement in the timing [from eGFR < 30 to ≥ 30 mL/min/1.73m2) of their recommended referrals based on their use of creatinine versus eGFR.

Results

Primary care physicians recommended subspecialty referrals later (CKD more advanced) when using creatinine versus eGFR to assess kidney function [median eGFR 32 versus 55 mL/min/1.73m2, p < 0.001]. Forty percent of primary care physicians significantly improved the timing of their referrals when basing their recommendations on eGFR. Improved timing occurred more frequently among primary care physicians practicing in academic (versus non-academic) practices or presented with White (versus African American) hypothetical patients [adjusted percentage(95% CI): 70% (45-87) versus 37% (reference) and 57% (39-73) versus 25% (reference), respectively, both p ≤ 0.01).

Conclusions

Primary care physicians recommended subspecialty referrals earlier when using eGFR (versus creatinine) to assess kidney function. Enhanced use of eGFR by primary care physicians' could lead to more timely subspecialty care and improved clinical outcomes for patients with CKD.