Referral for Dialysis in Ontario

BACKGROUND: Because the incidence rates of treated end-stage renal disease are much lower in Canada than in the United States, we hypothesized that decisions, made by family physicians and community internists, not to refer certain patients to nephrologists might explain this difference. OBJECTIVE: To elicit patterns of practice and attitudes from nonnephrologist physicians who care for, and possibly refer, patients with renal disease. METHODS: A mailed survey was sent to a random sample of 1924 members of the Ontario Medical Association, Sections on General and Family Practice and Internal Medicine. Of 1778 eligible respondents, responses were received from 728 physicians (40.9%). RESULTS: Patients with microscopic hematuria (79.2%), proteinuria (69.5%), and serum creatinine levels in the 120 to 150 mumol/L (1.4 to 1.7 mg/dL) range (84.3%) were generally not referred by family physicians. A hypothetical question about patient age and comorbid features revealed that physicians were less likely to refer patients as their age and comorbidity increased. In response to the question, "In the past 3 years, did you care for a patient who, after due consideration, died of renal failure without referral for dialysis," 14.2% of family physicians and 44.6% of internists said yes. Overall, 67.4% of respondents strongly or somewhat agree that rationing of dialysis is occurring now. Opinions about possible criteria for rationing of dialysis were that the majority strongly or somewhat agreed to basing a decision on the wishes of a competent patient (94.1%), short life expectancy (87.9), poor quality of life (87.0%), and age (63.6%). CONCLUSIONS: These results suggest that nonreferral for dialysis occurs in Ontario and that the act of referral, or nonreferral as the case may be, is influenced by both age and coexisting disease. The patterns of nonreferral reported raise a concern that patients who might benefit are not being referred to dialysis centers.