Referral of elderly patients with severe renal failure: questionnaire survey of physiciansBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7055.466 (Published 24 August 1996) Cite this as: BMJ 1996;313:466
- R G Parry, renal registrara,
- A Crowe, renal registrara,
- J M Stevens, consultant physiciana,
- J C Mason, consultant physiciana,
- P Roderick, senior lecturerb
- a Wessex Renal and Transplant Unit, St Mary's Hospital, Portsmouth PO3 6AD
- b Wessex Institute of Public Health Medicine, Southampton General Hospital, Southampton SO9 4XY
- Correspondence to: Dr R G Parry, Renal Unit, Southmead Hospital, Bristol BS10 5NB.
- Accepted 8 March 1996
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 treatment were over 75 compared with 3% in 1982.
Dialysis is feasible in elderly people,1 2 3 but there may be bias against referring elderly patients with renal failure to nephrologists.2 3 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 results
We 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 dialysis unit within their hospital (P<0.05 in χ2 test) or early review by a nephrologist was possible (P<0.001 in χ2 test). Nephrologists stated that pressure on dialysis services was not a contraindication to acceptance.
Although there may be under-referral of elderly patients with renal failure to nephrologists, physicians as a whole were liberal in their stated referring or accepting practice. This is very different from the results of a similar questionnaire study by Challah et al in 1984.5 Though no direct comparison is possible given the different case histories, nephrologists then rejected a mean of 4.7 of 16 cases and physicians a mean of 7.4. Other studies have shown that the presence of comorbidity4 and availability of dialysis facilities3 may influence referral rates.
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 people and have implications for the development of renal services.
We thank all the doctors who completed and returned the questionnaires, and Mr Bernard Higgins, statistician at the University of Portsmouth.
Conflict of interest None.