Referral of elderly patients with severe renal failure: questionnaire survey of physicians

Abstract

The proportion of elderly people in the United Kingdom is increasing. The increasing number of those with renal failure is reflected in an increase in the total number of elderly patients receiving renal replacement. In 1992, 12% of patients undergoing such treatmnent were over 75 compared with 3% in 1982.Dialysis is feasible in elderly people,`' but there may be bias against referring elderly patients with renal failure to nephrologists."4 The reasons for low referral rates are unclear but may include lack of resources, poor prognosis, or judgments about the quality of life of elderly people. To study the factors applying to the referral of elderly patients with renal failure we undertook a questionnaire survey of hospital physicians. Subjects, methods, and resultsWe sent 203 questionnaires to general physicians and elderly care physicians and 20 to nephrologists based in the south west of England and the Channel Islands. The questionnaire consisted of 14 brief case histories (see table 1) of patients aged 65-87 who were likely to need renal dialysis to survive. Physicians other than nephrologists were asked if they would refer the patient to a nephrologist for assessment while nephrologists were asked if they would accept the patient on to their dialysis programme. Further questions asked about the factors that would increase the probability of or would act as contraindications to referral or acceptance.A total of 165 questionnaires were returned; nine were blank (70% response rate; 18/20 (90%) nephrologists and 138/203 (68%) physicians responded). More patients in the 14 case histories would have been accepted by the nephrologists than would have been referred by physicians (median 13 v 10; P<0.001 in Mann-Whitney U test). Table 1 shows the relative frequency of acceptance or referral for each case in rank order. Most nephrologists and physicians would accept or refer a patient if either the patient or the relatives wished treatment. Only a few in both groups thought that fear of a law suit would make any difference to referral or acceptance. Both liver metastases and dementia were regarded as contraindications to dialysis by most physicians and nephrologists (by 133 and 129 physicians respectively and by 17 and 16 nephrologists respectively). Age was not a contraindication except when a patient was over 80, when 79 physicians (57%) and seven (39%) nephrologists thought it was a relative contraindication. Myeloma, hemiplegia, faecal incontinence, and being bed bound were thought to be only relative contraindications to treatment by most physicians and nephrologists.Physicians were more likely to refer if they had a Although our questionnaire measured only attitudes and not behaviour, the findings are consistent with a rising acceptance rate of elderly patients on to dialysis programmes. Elderly patients often have clinically significant comorbidity, develop complications on dialysis, and need a lot of social support. These factors point to the need for a multidisciplinary approach to treatment of elderly peop...

Octogenarians Reaching End-Stage Renal Disease

“…The low proportion of diabetes in this age segment (3) may reflect a survival disadvantage of diabetes over other illnesses leading to ESRD, such as hypertensive nephrosclerosis (which accounted here for nearly one half of renal diseases), or a reluctance of family physicians to refer diabetic patients with high comorbidity. Moreover, frequent nonreferral of pre-ESRD octogenarians to nephrologists has been suggested by surveys conducted in Canada and Europe (19,20). Patient se- 4 (6.6) 1 (2.6) lection that may have occurred at the primary care level (i.e., deciding who to refer to a nephrologist) is an important limitation in generalizing the results reported in this study.…”

Patient and Health Care Professional Decision-Making to Commence and Withdraw from Renal Dialysis

“…These support patient preferences while acknowledging the limitations in the evidence. A large number of quantitative studies have looked at physiologic (7-10), social (8,(10)(11)(12)(13)(14), educational (15)(16)(17), and geographic factors (18) that influence the decision to commence and withdraw from dialysis (15)(16)(17)(18)(19)(20)(21)(22). These studies have provided insights into influential factors, but their largely survey-based methods do not further our understanding of why and how different factors operate.…”

Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis

“…358 Similar rationing by physicians was not, however, demonstrated in a survey conducted in England. 368 Specialists (other than nephrologists) were likely to recommend referral for patients with CKD later than primary care physicians. 368 In a survey of referring physicians, Campbell 369 documented the reasons for late referral.…”

“…368 Specialists (other than nephrologists) were likely to recommend referral for patients with CKD later than primary care physicians. 368 In a survey of referring physicians, Campbell 369 documented the reasons for late referral. These included perception by the referring physicians of being evaluated negatively by nephrologists in 43% of cases, lack of communication or faulty communication between primary care physicians and nephrologists (37%), and lack of specific referral criteria for patients with ESRD (31%).…”