End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain

Underutilization of partial nephrectomy for stage T1 renal cell carcinoma in the United States, trends from 2000 to 2008. A long way to go

INTRODUCTION

Recent American Urologic Association Guidelines for small renal masses recommend partial nephrectomy for surgical treatment of T1 renal masses to preserve renal function and minimize cardiovascular comorbidities. This procedure is performed more often than in the past, after the technical issues of hemorrhage, fistula, and technique evolved. We reviewed the trends, practice patterns, and application of partial nephrectomy for T1 renal cell carcinoma in the United States from 2000 to 2008, before the American Urologic Association Guidelines. The objective is to investigate whether economic or societal factors favor the use of partial over radical nephrectomy surgery.

METHODS

Data on 142,194 cases from 1267 hospitals diagnosed with kidney and renal pelvis cancer in the National Cancer DataBase from 2000 to 2008 were the basis of the study.

RESULTS

Partial nephrectomy rates for stage T1 kidney and renal pelvis cancer have increased from 17% in 2000 to 31% in 2008. Differences in partial nephrectomy rates that arise from sex or race were not large. However, there was a disproportionate increase based on income and education. Also, there were differences based on insurance status; patients with managed care, in the military and veterans had higher partial nephrectomy rates. Partial nephrectomy rates were higher in teaching and research hospitals and in veterans hospitals. Geographically, the procedure was performed at higher rates in the eastern and midwestern parts of the country.

CONCLUSIONS

Partial nephrectomy rates for stage T1 renal cell carcinoma increased from 17% in 2000 to 31% in 2008. The procedure has been used preferentially with patients who are more educated and have high incomes.

Older peoples' satisfaction with home-based dialysis

BACKGROUND

The proportion of older people receiving dialysis is rapidly increasing. The typical choice for older patients is between home-based peritoneal dialysis (PD) and clinic-based haemodialysis (HD). Some centres have been successful in encouraging all patients - including older patients - to have home-based self-administered PD or HD.

AIM

To (i) describe the overall satisfaction with renal services among older patients dialysing, or in training, with HD or PD at home; and (ii) examine the relationship between residential distance from the nephrology unit and satisfaction with home-based dialysis.

METHODS

Participants were aged 60 years or more; and were either dialysing at home or training for dialysis at home. Two methods of cross-sectional data collection were used: (i) structured quantitative interviews with all participants; and (ii) qualitative interviews with a selected subgroup.

RESULTS

Participants comprised 45 patients on dialysis (94% of 48 eligible). Their average age was 68 years. Duration of dialysis averaged 28 months (range 3-150 months). Ratings of 'very good or excellent' were reported for dialysis treatment by 40 (89%) patients. Patients on dialysis, despite experiencing frustration with dialysis itself, expressed satisfaction across four categories: staff, information provision, involvement in decision-making and confidence in managing dialysis. Dissatisfaction was infrequent.

CONCLUSION

This pilot study suggests that older patients trained to dialyse at home using PD or HD are highly satisfied with the nephrology service - even when living remote from the nephrology unit. Home-based dialysis is possible in older patients with levels of comorbidity and disease severity as serious as elsewhere.

Serum creatinine is an inadequate screening test for renal failure in ischemic stroke patients

OBJECTIVE

Serum creatinine (SCr) level is the most commonly used screening test for renal function, but its concentration is affected by factors other than glomerular filtration rate (GFR). We hypothesized that SCr would underestimate the degree of renal failure in ischemic stroke patients.

MATERIAL AND METHODS

We conducted a prospective study of 273 patients admitted to our institution for ischemic stroke within a year. GFR was calculated using the Cockcroft-Gault formula (CG). Patients were grouped according to the SCr with stages of renal failure according to CG values.

RESULTS

Of the 273 patients studied, 231 had normal SCr. Of this group 46.8% (108), 24.7% (57) and 4 (1.7%) had mild, moderate and severe renal failure according to GFR estimation. Among patients with normal SCr, abnormal CG values were identified in 86.2% (150) > or = 65 years old, 33.3% (19) <65 years old, 69% (89) in men and 78.4% (80) in women. An SCr greater than 1.7 mg/dl had only a sensitivity of 14.7%.

CONCLUSIONS

This study documents the substantial prevalence of significantly abnormal renal function among patients with normal-range SCr. Routine estimation of GFR be preferred to SCr as a screening method for the early detection of renal impairment in stroke patients.

Older adults and chronic kidney disease decision making by primary care physicians: a scholarly review and research agenda

BACKGROUND

Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults.

OBJECTIVE

This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD.

RESULTS

While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD.

CONCLUSIONS

More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.

Prevalence and determinants of physician bedside rationing: data from Europe

BACKGROUND

Bedside rationing by physicians is controversial. The debate, however, is clouded by lack of information regarding the extent and character of bedside rationing.

DESIGN, SETTING, AND PARTICIPANTS

We developed a survey instrument to examine the frequency, criteria, and strategies used for bedside rationing. Content validity was assessed through expert assessment and scales were tested for internal consistency. The questionnaire was translated and administered to General Internists in Norway, Switzerland, Italy, and the United Kingdom. Logistic regression was used to identify the variables associated with reported rationing.

RESULTS

Survey respondents (N=656, response rate 43%) ranged in age from 28 to 82, and averaged 25 years in practice. Most respondents (82.3%) showed some degree of agreement with rationing, and 56.3% reported that they did ration interventions. The most frequently mentioned criteria for rationing were a small expected benefit (82.3%), low chances of success (79.8%), an intervention intended to prolong life when quality of life is low (70.6%), and a patient over 85 years of age (70%). The frequency of rationing by clinicians was positively correlated with perceived scarcity of resources (odds ratio [OR]=1.11, 95% confidence interval [CI] 1.06 to 1.16), perceived pressure to ration (OR=2.14, 95% CI 1.52 to 3.01), and agreement with rationing (OR=1.13, 95% CI 1.05 to 1.23).

CONCLUSION

Bedside rationing is prevalent in all surveyed European countries and varies with physician attitudes and resource availability. The prevalence of physician bedside rationing, which presents physicians with difficult moral dilemmas, highlights the importance of discussions regarding how to ration care in the most ethically justifiable manner.

[Chronic kidney disease: do generalists and nephrologists differ in their care?]

INTRODUCTION

Chronic kidney disease (CKD) is a major public health problem. We report an evaluation of the CKD perception from a French family physician's (FP) point of view.

METHODS

A questionnaire was sent to a representative and independently selected sample of 497 FP, i.e. 20% of the FP working in the administrative region Lorraine. There were 214 completed surveys, i.e. response rate: 43%.

RESULTS

Age of FP was: < 40 years of age: 13%, 40-50: 40%, > 50: 47%. The geographic working place was urban: 41%, rural: 22%, urban and rural: 37%. Ninety-nine per cent of FP has a nephrologist, devoted to CKD referral. Twenty-one per cent of FP has a comprehensive picture of CKD and 75% thinks that CKD diagnostic is difficult Thirty per cent of FP were aware of CKD guidelines. For FP, risk-factors for CKD were: hypertension: 93%, diabetes: 99%, age over 65: 64%, urinary infection: 34%, hematuria/proteinuria: 78%, anaemia: 43%, therapeutics associated with risk of renal injury: 79%, all of these circumstances: 20%. The referral decision to a nephrologist was done at a mean creatinine clearance of 41+/-12 ml/min. Age over 80, dementia, and cancer were considered to be a contra-indication of renal replacement therapy, for respectively 30%, 69%, and 63% of FP. CME was associated with better awareness of guidelines, and use of clearance rather than serum creatinin.

CONCLUSION

From FP point of view, overall awareness of CKD guidelines is low. In the context of the current nephrology services, greater sharing of CKD care with FP is needed.

Late referral for assessment of renal failure

It has been recommended that adult patients with a serum creatinine above 150 mumol/l should be referred to a nephrologist for specialist assessment. This study ascertained all patients in Northern Ireland with creatinine above this concentration in 2001 (n = 19 286 ) to see if this triggered referral within the subsequent year. After exclusion of those who were already known to a nephrologist and those who had acute renal failure, it was found that younger patients and diabetic patients were more likely to be referred. There was no difference in referral rates between male and female patients. However, only 6.5% of all non-diabetic subjects and 19% of diabetic patients were referred within 12 months after a first increased serum creatinine test.

Early referral to a nephrologist is associated with better outcomes in type 2 diabetes patients with end-stage renal disease

OBJECTIVE

End-stage renal disease (ESRD) requiring renal replacement therapy (RRT) is a late complication of type 2 diabetes. The correlation between pre-ESRD medical care and outcome has been rarely studied in France.

METHODS

Community-based study of case-incIdent ESRD patients. Medical care practices were described retrospectively when starting RRT. Medical status, mortality, morbIdity, and quality-of-life were recorded prospectively.

RESULTS

One hundred and fourty-eight ESRD patients with type 2 diabetes were included. Factors independently correlated with mortality within 3 Months of RRT onset were presence of physical impairment of ambulation at onset of RRT [odd ratio (OR): 5, (95%CI: 1.9-13.3)], and starting RRT in life-threatening circumstances [OR: 3.6, (95%CI: 1.2-10.7)]. Factors independently correlated with "poor outcome" 1 Year after the onset of RRT were BMI less than 20 kg/m2 [OR: 13.4, (95%CI: 1.5-120.2)] and presence of 2 [OR: 2.7, (95%CI: 0.9-8.4)], or 3 or more comorbId conditions [OR: 4, (95% CI: 1.4-11)]. Three Months after the first RRT session, survival was 16.4% better for patients who had had regular nephrological care versus none, and 9.1% better for those who had had late nephrological care versus none. Type 2 diabetes patients starting RRT in an emergency setting had had significant less regular nephrological care. Length of their first hospital stay was significantly longer. They were more likely to have lower resIdual renal function, gastrointestinal symptoms, lower serum albumin, lower hematocrit, lower serum calcium, and higher serum phosphorus.

CONCLUSIONS

During the course of chronic renal failure in type 2 diabetes patients, early implementation of nephrological well-established guIdelines is associated with better outcome after starting RRT.

Are Older Cancer Patients Being Referred to Oncologists? A Mail Questionnaire of Ontario Primary Care Practitioners to Evaluate Their Referral Patterns

Purpose: Understanding why older patients are frequently underrepresented in cancer services use and clinical research may help to increase their participation in clinical trials and eventually result in better cancer care for this vulnerable population.

Methods: To identify potential barriers that may prevent older cancer patients from being referred from a primary care physician (PCP) to an oncology specialist, a self-administered questionnaire was mailed to 9,312 PCPs throughout Ontario.

Results: With a one-time mailing, 2,240 questionnaires were returned (response rate, 24%) of which 2,089 (93%) were assessable. Although 86% of respondents would refer most older patients with early-stage, potentially curable cancers to oncologists, only 65% would refer those with advanced-stage, potentially incurable cancers. The factors that most influence referral decisions of PCPs are patient’s desire to be referred (69%), type (54%) and stage (49%) of cancer, and severity of cancer symptoms (49%). Other factors including age do not seem to influence the referral decision. Approximately 9% of respondents found it difficult to refer older cancer patients to oncology specialists, with the most commonly cited barriers being the length of waiting lists, mandatory tissue diagnosis before referral, and the belief that oncologists seldom relate to PCPs.

Conclusion: Most PCPs stated that they would refer all elderly patients with cancer to oncologists and that referral decisions were based mainly on patients’ wishes. Continued efforts are needed to overcome barriers in the referral process and to understand the perspectives of elderly patients to enhance their cancer care.

Chronic kidney disease: issues and establishing programs and clinics for improved patient outcomes

The spectrum of chronic kidney disease (CKD) extends from the point at which there is slight kidney damage, but normal function, to the point at which patients require either a renal transplant or renal replacement therapy to survive. Epidemiological studies suggest there are approximately 20,000,000 patients with various stages of CKD. These patients have many comorbidities, including cardiovascular disease, hypertension, diabetes, anemia, nutritional and metabolic derangements, and fluid overload. Unfortunately, evidence shows that current CKD care in the United States is suboptimal, and late referral to a nephrologist is often the rule and not the exception. Roles of primary care physicians (PCPs) and nephrologists in the care of patients with CKD remain undefined. Several studies have suggested that care provided by multidisciplinary nephrology teams can improve patient outcomes. Currently, there are published evidence-based clinical practice guidelines for anemia management, nutritional therapy, and vascular access placement, with other CKD guidelines under development. The intent of this review includes providing compelling evidence for earlier screening, identification, and management of patients with CKD; showing that current CKD care is suboptimal; encouraging the development of multidisciplinary teams that provide collaborative care to patients with CKD, suggesting roles for PCPs and nephrologists in the care of these patients; describing CKD initiatives from national organizations; and providing a comprehensive checklist that can guide the development of CKD clinics and programs.

Epidemiology and demographic aspects of treated end-stage renal disease in the elderly

Over the last 10 years an increasing number of patients worldwide have started dialysis or had transplantation. Many are elderly with complex comorbid conditions. Registries across the world all show a rapid and dramatic increase in the number of older patients accepted for renal replacement therapy. In addition, the number of patients who grow old on dialysis is increasing, leading to a marked change in the demographics of the renal population. Changes over time and across registries are discussed with reference to patient characteristics, survival statistics, and the trends seen with transplantation in the elderly.