Original Investigation
Pathogenesis and Treatment of Kidney Disease and Hypertension
Identification and Referral of Patients With Progressive CKD: A National Study

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Background: It is unclear whether primary care physicians (PCPs) and nephrologists differ in their recognition of progressive chronic kidney disease (CKD), agree on diagnostic and referral strategies, and identify similar barriers to caring for patients. Methods: We conducted a national study of PCPs and nephrologists in the United States through a questionnaire describing a PCP caring for a patient with progressing CKD and questions to assess recognition of kidney dysfunction and approaches to diagnostic evaluation and referral. We identified participant and patient characteristics independently associated with CKD recognition and referral. Results: We randomly identified a national sample of 304 physicians (126 nephrologists [39% response rate], 89 family physicians [28% response rate], and 89 general internists [28% response rate]). PCPs recognized CKD less (adjusted percentage, 59%; 95% confidence interval [CI], 47 to 69, family physicians; adjusted percentage, 78%; 95% CI, 67 to 86, general internists; adjusted percentage, 97%; 95% CI, 93 to 99, nephrologists; P < 0.01), differed from nephrologists in their recommendations for diagnostic testing, and recommended referral less (adjusted percentage, 76%; 95% CI, 65 to 84, family physicians; adjusted percentage, 81%; 95% CI, 70 to 89, general internists; adjusted percentage, 99%; 95% CI, 95 to 100, nephrologists; P < 0.01). PCPs differed from nephrologists in their expected intensity of specialists’ involvement in care (16%, family physicians; 20%, general internists; 6%, nephrologists recommending nephrologist input monthly to every 6 months; P = 0.01). Lack of awareness of clinical practice guidelines and lack of clinical and administrative resources were identified as important barriers to care. Conclusion: PCPs recognize and recommend specialist care for progressive CKD less than nephrologists and differ in their clinical evaluations and expectations for referral. Improved dissemination of existing guidelines and targeted education in conjunction with efforts to build consensus among PCPs and nephrologists regarding their roles in the care of patients with CKD, including the collaborative development of clinical practice guidelines, could enhance patient care.

Section snippets

Study Design

We conducted a national cross-sectional study of PCPs and nephrologists in the United States between August 2004 and August 2005 by using a self-administered mailed questionnaire designed to ascertain physicians’ approaches to the identification, evaluation, and referral of patients with NKF-KDOQI stages 3 (GFR, 30 to 59 mL/min/1.73 m2 [0.50 to 0.98 mL/s]) and 4 (GFR, 15 to 29 mL/min/1.73 m2 [0.25 to 0.48 mL/s]) CKD, a group at high risk for progression of CKD and associated morbidity. We

Response Rate, Scenario Randomization, and Physician Characteristics

Of 1,200 physicians initially targeted, 131 had moved, were no longer contactable, or had incorrect addresses; 52 were not PCPs or nephrologists; and 58 were dead or no longer practicing medicine (total, 241 ineligible physicians). Of the remaining 959 eligible physicians, 304 physicians responded (comprising 178 PCPs [89 family physicians and 89 general internists] and 126 nephrologists; 28% response rate for family physicians, 28% for general internists, 39% for nephrologists). There were no

Discussion

In this study of physicians sampled randomly from across the United States, our findings suggest that efforts to raise physicians’ awareness of progressive CKD and disseminate recently developed clinical practice guidelines have not been as effective as hoped.17, 18 Our findings highlight that PCPs and nephrologists have different perceptions of how the evaluation of patients with progressive CKD should be undertaken and the intensity with which specialists should be involved in their care.

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    Originally published online as doi:10.1053/j.ajkd.2006.04.073 on June 14, 2006.

    Support: Funding sources are National Kidney Foundation of Maryland Mini-Grant (L.E.B.); Robert Wood Johnson Harold Amos Faculty Development Program (L.E.B.); Grant no. K240502643 from National Institute of Diabetes and Digestive and Kidney Diseases (N.R.P.). Potential conflicts of interest: None.

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