Referral for dialysis in Ontario

Area of Science:

• Nephrology
• Public Health
• Medical Practice Patterns

Background:

• Lower incidence rates of treated end-stage renal disease (ESRD) in Canada compared to the US suggest potential differences in referral practices.
• Hypothesized that non-referral of certain patients to nephrologists by primary care physicians and community internists contributes to this disparity.

Purpose of the Study:

• To investigate practice patterns and physician attitudes regarding the referral of renal disease patients.
• To understand decision-making processes of non-nephrologist physicians involved in the care of patients with kidney disease.

Main Methods:

• A mailed survey was distributed to a random sample of 1924 general and family practitioners and internists in Ontario.
• Responses were collected from 728 physicians (40.9% response rate).

Main Results:

• Non-referral was common for patients with microscopic hematuria, proteinuria, and mild elevations in serum creatinine.
• Physicians were less likely to refer older patients or those with significant comorbidities.
• A notable percentage of physicians (14.2% family physicians, 44.6% internists) reported caring for patients who died of renal failure without dialysis referral in the past 3 years.
• A majority of respondents agreed that dialysis rationing is occurring and supported criteria such as patient wishes, life expectancy, quality of life, and age for such decisions.

Conclusions:

• Non-referral for dialysis is a documented practice in Ontario, influenced by patient age and comorbidities.
• These referral patterns suggest that some patients who could benefit from dialysis may not be receiving it.
• The findings highlight potential inequities in access to renal replacement therapy.