Abstract
BackgroundPrimary 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.MethodsWe 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.ResultsPrimary 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).ConclusionsPrimary 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.
Highlights
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
We asked physicians several questions regarding their preferred management of patients with progressing advanced CKD, including two questions to assess the threshold of kidney function at which they would refer patients for subspecialty care based on their use of either serum creatinine or estimated glomerular filtration rate (eGFR) to estimate kidney function
To assess the effect of primary care physicians’ use of eGFR on the timing of their subspecialty referral decisions, we presented them with two visual analog scales, one featuring a range of numbers reflecting kidney function measured using serum creatinine [ranging from “6.0 mg/dL”] and one featuring numbers reflecting kidney function measured using eGFR [ranging from 120 mL/ min/1.73m2 to 0 mL/min/1.73m2]
Summary
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. Referral of patients with CKD to specialist care has been shown to improve the morbidity and mortality outcomes[5,6,7,8] Despite these recommendations, primary care physicians, who care for a majority of the growing number of patients with stage 3 CKD, have been shown in multiple studies to have difficulties recognizing the severity of CKD, which may contribute to missed or late referrals[9,10,11,12,13,14,15,16,17,18,19]. A majority of larger laboratories in the U.S currently report eGFR (77%), less than half (38%) of all clinical laboratories nationwide calculate and report eGFR[22,23,24]
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