Research article

A systematic review of patient and health system characteristics associated with late referral in chronic kidney disease

Sankar D Navaneethan¹ , Sarah Aloudat² and Sonal Singh^3,4

¹  Division of Nephrology, University of Rochester, Rochester, NY, USA

²  Department of Medicine, University of Texas at Houston, TX, USA

³  Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA

⁴  MPH Program, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA

author email corresponding author email

BMC Nephrology 2008, 9:3doi:10.1186/1471-2369-9-3

Published:	25 February 2008

Abstract

Background

To identify patient and health system characteristics associated with late referral of patients with chronic kidney disease to nephrologists.

Methods

MEDLINE, CENTRAL, and CINAHL were searched using the appropriate MESH terms in March 2007. Two reviewers individually and in duplicate reviewed the abstracts of 256 articles and selected 18 observational studies for inclusion. The reasons for late referral were categorized into patient or health system characteristics. Data extraction and content appraisal were done using a prespecified protocol.

Results

Older age, the existence of multiple comorbidities, race other than Caucasian, lack of insurance, lower socioeconomic status and educational levels were patient characteristics associated with late referral of patients with chronic kidney disease. Lack of referring physician knowledge about the appropriate timing of referral, absence of communication between referring physicians and nephrologists, and dialysis care delivered at tertiary medical centers were health system characteristics associated with late referral of patients with chronic kidney disease. Most studies identified multiple factors associated with late referral, although the relative importance and the combined effect of these factors were not systematically evaluated.

Conclusion

A combination of patient and health system characteristics is associated with late referral of patients with chronic kidney disease. Overall, being older, belonging to a minority group, being less educated, being uninsured, suffering from multiple comorbidities, and the lack of communication between primary care physicians and nephrologists contribute to late referral of patients with chronic kidney disease. Both primary care physicians and nephrologists need to engage in multisectoral collaborative efforts that ensure patient education and enhance physician awareness to improve the care of patients with chronic kidney disease.