attitudes of canadian nephrologists toward multidisciplinary team–based ckd clinic care
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Attitudes of Canadian Nephrologists Toward MultidisciplinaryTeam–Based CKD Clinic Care
David C. Mendelssohn, MD, Edwin B. Toffelmire, MDCM, and Adeera Levin, MD
Background: Although evidence supporting the advantages of multidisciplinary team–based chronic kidneyisease (CKD) care is not well developed, many groups are advocating increased availability of this model.ethods: The research design is a mailed survey sent to 523 members of the Canadian and Quebec Societies ofephrology. Results: After excluding 113 respondents who declared themselves to be ineligible, the response rateas 54%. Ninety-one percent of nephrologists reported that they usually or always use a CKD clinic. Decisionsbout when to perform CKD-related tasks were based mainly on an estimate of glomerular filtration rate, rather thanime remaining before end-stage renal disease (ESRD). The ideal creatinine clearance for referral to a CKD clinicas 30 to 59 mL/min (0.50 to 0.98 mL/s), but the usual level was 20 to 29 mL/min (0.33 to 0.44 mL/s). The ideal time for
eferral was more than 12 months before ESRD. Renal replacement therapy discussions were initiated at areatinine clearance of 20 to 29 mL/min (57%). Nephrologists supported promotion of home dialysis for suitableatients, but not mandating this. Nephrologists did not provide a blunt prognosis to patients who did notpecifically ask. Late referral based on adequate time for ESRD preparation was reported to be 4 to 6 months (27%),to 9 months (26%), or 10 to 12 months (30%). Thirty-eight percent said that optimal preparation takes 13 months or
onger. Conclusion: The literature’s common definition of less than 3 months as a cutoff value between late andarly referral is not endorsed. Given that multidisciplinary team–based care is widely available in Canada, this studyight inform other jurisdictions about the merits and problems associated with multidisciplinary team–based care
nd might shape the agenda for future empirical research. Am J Kidney Dis 47:277-284.2006 by the National Kidney Foundation, Inc.
NDEX WORDS: Chronic kidney disease (KD); survey; nephrologists; referral; prognosis.
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HERE IS A GROWING belief, first ex-pressed in a National Institutes of Health
eport more than 10 years ago, that multidisci-linary team (MDT)–based chronic kidney dis-ase (CKD) care is superior to care provided byephrologists not working with such a team.1,2
ecent prospective, but nonrandomized, trialshowed a survival advantage for patients man-ged by an MDT.3,4 MDT-based CKD care usu-lly includes direct patient care by a nephrolo-ist, nurse, dietician, social worker, and,ometimes, pharmacist.
Notwithstanding this, MDT-based CKD cares not funded in many jurisdictions and is notsed widely in the United States or many otherountries. Furthermore, many aspects of CKDare (with or without an MDT care component)emain poorly defined and variably applied inlinical practice.
Canada has a unique health care system. Forhe most part, end-stage renal disease (ESRD)nd CKD care are integrated and centralized inospital-based facilities. In some provinces, theovernment made decisions to fund these facili-ies for MDT-based CKD care. In others, theacility-based ESRD program leadership takesesponsibility for providing both high-qualityKD and ESRD care and moves funds intended
or ESRD care to offset the costs of MDT-based
merican Journal of Kidney Diseases, Vol 47, No 2 (February), 20
KD care. Irrespective, these strategies haveontributed to the development and evolution ofDT-based CKD care in Canada.We administered a comprehensive mailed sur-
ey questionnaire to Canadian nephrologists toxplore physician attitudes to and practical usef CKD care.
METHODS
The research design is a mailed self-administered surveyent to 523 members of the Canadian Society of Nephrology
From the Department of Nephrology, Humber River Re-ional Hospital; University of Toronto, Weston; Division ofephrology, Kingston General Hospital; Departments ofedicine and Pharmacology and Toxicology, Queen’s Uni-
ersity, Kingston, ON; and Division of Nephrology, Univer-ity of British Columbia, St Paul’s Hospital, Vancouver, BC,anada.Received August 19, 2005; accepted in revised form
ctober 18, 2005.Originally published online as doi:10.1053/j.ajkd.2005.10.019
n January 4, 2006.Support: Funded by MOMENTUMTM, a collaboration
etween Ortho Biotech (a division of Janssen-Ortho Inc)nd Baxter Inc. Potential conflicts of interest: None.Address reprint requests to David C. Mendelssohn, MD, Hum-
er River Regional Hospital, 200 Church St, Rm 2024, Weston,N, M9N 1N8 Canada. E-mail: [email protected]© 2006 by the National Kidney Foundation, Inc.0272-6386/06/4702-0008$32.00/0
doi:10.1053/j.ajkd.2005.10.01906: pp 277-284 277
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MENDELSSOHN, TOFFELMIRE, AND LEVIN278
nd the Quebec Society of Nephrology. English and Frenchersions were targeted to the specific audiences. The survey,ith a cover letter, initially was mailed in spring 2004, withfollow-up mailings to nonrespondents in summer 2004 and
anuary 2005.The questionnaire (see Appendix online with this article at
ww.ajkd.org) was designed to survey a number of areas ofKD care, including demographics of physician respon-ents, local availability of MDT-based CKD clinics, howecisions in CKD care are timed (referral for education,ascular access creation, and so on), what information isrovided to patients and who provides it, what defines a lateeferral, and other aspects. Questionnaire respondents wereept anonymous. The survey instrument initially was pilotested on a sample of 3 nephrologists and modified accord-ngly. Questions were constructed so that answers could beiven according to multiple choice closed answers or astatements with which respondents could agree or disagreen a 5-point Likert scale.The mailing, administration, data entry, and data analysis
f survey questionnaires were done by Northstar Researchartners (Toronto, Canada). Data were analyzed using Mer-
in Tabulation/Analysis Suite, Data Analysis Systems andervices (DATAN), Skillman, NJ, 2005. Results were ana-
yzed by using univariate statistics. This research projectas approved by the Research Ethics Board of Queen’sniversity, Kingston, ON, Canada.
RESULTS
Five hundred twenty-three surveys originallyere mailed, and 113 respondents declared them-
elves ineligible. The most common reasons werehat their practice was mainly research and lesshan 25% clinical (n � 29), their practice wasainly pediatric (n � 25), or they were retired (n25). Other reasons included that their practice
as mainly transplantation, mainly administra-ion, they were not physicians, or they no longerracticed in Canada.Demographics of the 221 respondent nephrolo-
ists are listed in Table 1. Respondent nephrolo-ists had been in practice a mean of 14.2 years.n terms of geographic distribution, 36.7% wererom Ontario, 30.8% were from Quebec, 23.5%ere from the 4 western provinces, and 8.5%ere from 3 eastern provinces. The respondentephrologists were heavily involved in clinicalork. This profile and distribution are very simi-
ar to that reported in a recent Canadian Societyf Nephrology human resources planning sur-ey, suggesting that our sample is representativef Canadian nephrologists.5
More than 96% of nephrologists reported thathey had easy access to an MDT-based CKD
linic, and 90.9% said they always or usually ased this clinic. Only 2.3% said they rarely orever used the CKD clinic (data not shown).Figure 1 shows the response of nephrologists
bout whether they make decisions about CKDasks based on kidney function or based onstimated months before ESRD. Only 16.9%eported that they based decisions on expectedonths before ESRD. Estimates of kidney func-
ion (eg, calculated creatinine clearance [CrCl])ere the most common methods used to guideKD decisions.
eferral to the MDT Clinic
Referral to the MDT-based CKD clinic waseported by 57% of nephrologists to occur whenrCl was between 20 and 29 mL/min (0.33 and.48 mL/s) and 31.3% referred patients to the clinichen CrCl was between 30 and 59 mL/min (0.50
nd 0.98 mL/s), whereas a minority (7.9%) referredo the clinic at much lower levels of function (CrCl,0 to 19 mL/min [0.17 to 0.32 mL/s]). In an idealorld with optimal resources, 64.5% of nephrolo-ists would refer patients to the clinic when CrClas greater than 30 mL/min (�0.50 mL/s). Discus-
ions about renal replacement therapy options wereeported to be initiated when CrCl was 30 to 59L/min (0.50 to 0.98 mL/s) by 31.2% of nephrolo-
ists, whereas 58.7% started these discussions whenrCl was 20 to 29 mL/min (0.33 to 0.48 mL/s; dataot shown).
eferral for Vascular Access
Figure 2 describes the level of kidney function
Table 1. Demographics of Respondent Nephrologists
ype of practice (%)Community-based group 28Community-based solo 8University-based group 64ialysis work (%)All HD 9Mostly HD 52Mixed 30Mostly PD 1All PD 1None 6linical work (%)�76 6851–75 1826–50 12�25 2
Abbreviation: PD, peritoneal dialysis.
t which the nephrologist or CKD team member
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MULTIDISCIPLINARY TEAM–BASED CKD CARE 279
ould refer a patient who has chosen hemodialy-is (HD) for vascular access surgery. CrCl of 20o 29 mL/min (0.33 to 0.48 mL/s) was theesponse of 49.6% of nephrologists, but 40.0%aited until CrCl was 10 to 19 mL/min (0.17 to.32 mL/s). When framed as time before ESRD,4.5% said 9 to 12 months, 33.8% said 6 to 8onths, and 28.2% said 3 to 5 months (data not
hown).
enal Replacement Therapy Choices
Table 2 describes the frequency with which aephrologist or CKD team member told patientsbout possible choices as they approached ESRD.f note, although peritoneal dialysis and in-
enter HD were almost always discussed, homeD, preemptive live donor transplantation, a
imited trial of dialysis, and the option of with-
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Fig 1. When I need to make deci-ions about when to do each of theKD tasks (eg, refer to multidisci-linary clinic, make final modalityecision, refer for arteriovenous ac-ess surgery), I make my decisionsased mostly on:
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ml m/ ni ml m/ ni ml m/ ni ml m/ nirawing from dialysis therapy at any time in theuture were not consistently disclosed as a choiceo patients. As shown in Fig 3, nephrologistsupported the presentation of information aboutenter-based and home dialysis in a way thatromotes home dialysis for suitable patients, butid not make it mandatory. They did not believehat suitable patients should be obligated to learnome dialysis.
isclosure of Prognosis
We probed issues around disclosure of progno-is to patients (Fig 4). A strong majority ofephrologists (94.1%) reported that they usuallyr always told patients that dialysis is a life-ustaining treatment and without it, they wouldie of kidney failure weeks or months after theidneys functioned at less than a critical level.
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Fig 2. At what level of CrClwould you (or a CKD team mem-ber) refer patients who have cho-sen HD for vascular access cre-
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ation? [To convert CrCl in mL/minto mL/s, multiply by 0.01667.]
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MENDELSSOHN, TOFFELMIRE, AND LEVIN280
imilarly, 81.7% usually or always gave patientsho specifically asked for it detailed and blunt
nformation about prognosis, eg, that life expect-ncy was reduced to one third that of anothererson of the same age without kidney disease.owever, only 38.4% reported that they usuallyr always disclosed this information to patientsho did not specifically ask for it.
arly and Late Referral
Figure 5 shows results of 2 survey questionsesigned to assess the perceived cutoff timeetween early and late referral. The questionsked respondents to define the cutoff as theinimum amount of time required to prepare a
atient for elective start on either modality. Ad-quate time was said to be between 4 and 12onths by 82.7%, whereas optimal preparation
ime was said to be longer than 10 months by8.2% of nephrologists.
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ot to have dialysis or transplantation 46.8ome HD 18.3ome PD 68.4reemptive live donor transplantation 31.5
n-center HD 72.7limited trial 22.5ithdrawal in future 37.9
Abbreviation: PD, peritoneal dialysis.
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The personnel available and their functionsithin the MDT-based CKD clinic were as-
essed. Nephrologists had excellent access to aurse (96.8%), social worker (94.6%), and dieti-ian (95.0%). Pharmacists were available lessommonly (65.4%; data not shown). Table 3 listshe person (or persons) in the clinic (in thepinion of the responding nephrologist) whourrently provides detailed information aboutarious issues. Physicians and nurses performedost of these functions. Nurses imparted certain
ypes of information much less frequently thanephrologists, and these areas included preemp-ive transplantation, prognosis, trial of dialysis,nd palliative care options. Conversely, nursesmparted information more often than nephrolo-ists about dialysis options. Despite excellentccess to social workers, nephrologists believed
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Fig 3. What is your opinionabout these aspects of CKD care inCanada? (A) I believe we shouldpresent information about center-based and home dialysis in a waythat promotes home dialysis forsuitable patients, but does notmake it mandatory. (B) I believe
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MULTIDISCIPLINARY TEAM–BASED CKD CARE 281
hey provided detailed information about ad-ance care planning and palliative care optionsess than 50% of the time and almost neverrovided information about prognosis.
ephrologists’ Attitudes and Opinions AboutTD-Based CKD Clinic
Figure 6 shows opinions of nephrologists abouteveral other issues; 94.5% strongly or some-hat agreed that overall, MTD-based CKD clin-
cs were superior compared with care providedy a nephrologist alone, and 83% of nephrolo-ists strongly or somewhat agreed that nurseractitioners can use algorithms for many as-ects of routine care of CKD patients, such thatirect contact with a nephrologist at each visitight not be necessary. Most nephrologists be-
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Fig 4. In my practice, I (or a CKDeam member): (A) tell my patientshat dialysis is a life-extending treat-
ent and that without it, they willie of kidney failure weeks oronths after the kidneys function
t less than a critical level; (B) givey patients who specifically ask
or it detailed and blunt informationbout prognosis, for example, thatife expectancy is reduced on aver-ge to one third that of another per-on of the same age without kidneyisease; (C) give even my patientsho do not specifically ask for itetailed and blunt informationbout prognosis, for example, thatife expectancy is reduced on aver-ge to one third that of another per-on of the same age without kidneyisease.
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ieved that although these clinics were cost-ffective, they were inadequately funded from aospital and physician’s point of view.
DISCUSSION
The epidemic of CKD and ESRD threatens toutstrip the ability of available nephrologists torovide comprehensive and high-quality care tohese patients. Nephrologists must shift theirractice from its traditional focus on ESRD toake the time required to care for patients withKD. Of note, CKD care is complex and timeonsuming.6,7 Several descriptions of MDT-ased CKD care in Canada were published previ-usly.2,3,8 It seems clear that new models of carere required to manage this problem, and MDT-
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Fig 5. The literature is unclearabout what the cutoff time betweenan early referral and late referralshould be. If the cutoff is definedas the minimum amount of timerequired to adequately (or opti-mally) prepare a patient for an elec-tive start on either modality, then,
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MENDELSSOHN, TOFFELMIRE, AND LEVIN282
ased CKD care is one such promising ap-roach.9
This survey adds new information concerninghe perceived benefits of MDT-based CKD care.anadian clinical nephrologists, who, in general,ave broad experience with this model of care,re strongly supportive of it. They believe itrovides superior education about treatmenthoices, and, importantly, they support the devel-pment of algorithms that might lead to patientisits when nephrology contact is not required.
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Fig 6. What is your opinion about these aspects olinics are superior compared with care provided by a nducation about treatment choices better than a nephrany aspects of routine care of patients with CKD, suce necessary. (D) Multidisciplinary CKD clinics leadephrologist practicing alone. (E) Multidisciplinary CK
Table 3. Who Is the Person in Your PracticAbout the F
Physician Nur
SRD choices 82.7 85ome HD 63.2 70eritoneal dialyses 68.2 91
n-center HD 71.4 86reemptive transplantation 89.1 47ascular access 78.6 74rognosis 99.6 16dvance care planning 70.0 42rial of dialysis 90.4 28alliative care option 90.4 35
F) Multidisciplinary CKD care is inadequately funded from a plinics are cost-effective.
his would seem best suited for stable, slowlyrogressive patients who have had issues ofeversibility addressed, have had measures imple-ented to slow progression and manage comor-
idities and cardiovascular risk factors, haveade modality decisions, and have a plan for
lective start of ESRD care in place. This mayeduce the burden of CKD care on limited ne-hrology human resources.Education, disclosure of information, and em-
owerment of patient decision making are key
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care in Canada? (A) Overall, multidisciplinary CKDlogist alone. (B) Multidisciplinary CKD clinics providet alone. (C) Nurse practitioners can use algorithms forirect contact with a nephrologist at each visit may note patients selecting a home dialysis method than ais inadequately funded from a hospital point of view.
Currently Provides Detailed Informationng Areas?
Social Worker Dietician Pharmacist
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MULTIDISCIPLINARY TEAM–BASED CKD CARE 283
asks for a CKD clinic. It appears there aremportant deficiencies in these areas that neph-ologists identified in our survey. For example, aignificant percent of patients may not be toldbout home HD, preemptive live donor transplan-ation, a limited trial of dialysis, and that dialysisight be withdrawn in the future. Similarly,
mportant prognostic information may be with-eld from patients who do not ask specifically fort. Recent guidelines and studies support com-lete disclosure, even in this uncomfortable cir-umstance.10,11 Importantly, this survey suggestshat social workers may not be helpful in facilitat-ng discussions in these areas either. Perhapsephrologists are reluctant to discuss treatmentptions that might not be available in their ownenter (eg, home HD). Furthermore, as recentlyescribed, complete disclosure of end-of-life in-ormation inherently is a complex and ambiva-ent task for them.11,12 These suboptimal actionshat might facilitate independence of patientsequire further exploration: there may be a roleor nonphysician MDT-based clinic personnel tongage more formally in the presentation of allhoices if physicians are not able to do so. Itould appear that these are some areas in whichDT-based CKD clinic performance could be
mproved.Most studies in the literature defined late refer-
al as 1, 3, or 4 months before ESRD.13-18 Manyegative outcomes associated with late referralre described, and certainly, early referral isdvocated.1,19-25 However, exactly where the lineetween an early and late referral should berawn is not clear and is difficult to define withsual research study designs. Our survey methoduggests there is an important difference be-ween what nephrologists think is the adequateompared with optimal time to prepare a patientor an elective start on dialysis therapy, and thatore time is required than the 3 months beforeSRD usually assigned to a late referral. Weelieve it may be timely to change how lateeferral is defined to reflect nephrologists’ cur-ent opinions more accurately. Furthermore, de-ermining the cutoff point that separates earlynd late referral requires more rigorous study.
The major factor that limits more widespreadse of MDT-based CKD care is cost. Salaryupport is required for nurses, social workers,
ieticians, pharmacists, and clerical staff. Further- sore, infrastructure-related costs for clinic space,verhead, and other items can be substantial. Theconomic analysis of CKD care is still in its earlytages.26,27 Our survey strongly suggests thatephrologists believe this MDT-based model isost-effective. We advocate strongly for moreconomic-based study to define exactly whichlements of MDT-based CKD care are cost-ffective and which elements may not be re-uired.Currently, clinical studies to define the role
nd impact of MDT-based CKD care on patientutcomes are ongoing in Canada. The Kidneyoundation of Canada has funded, in partnershipith 2 industry sponsors, the Canadian study of
are before dialysis (Can-CARE), a 4-year pro-pective observational study of patients newlyeferred to nephrologists (www.Kidney.ca; prin-ipal investigators, A. Levin, B. Barrett). Theanadian Institute for Health Research, in part-ership with the Kidney Foundation of Canada,ecently funded Canadian Prevention of Renalnd Cardiovascular Endpoints Trial (CanPRE-ENT), a randomized control trial examining
he outcomes of patients identified as havingidney disease, as a function of exposure to usualare versus protocolized multidisciplinary carewww.Kidney.ca; principal investigators, P.arfrey, B. Barrett, and A. Levin).The strengths of this study are the high re-
ponse rate and that respondents are highly in-olved in clinical dialysis work. Therefore, theseesults are highly representative of current Cana-ian expert opinion. There also are importantimitations. For example, opinions expressed in aurvey may not be what respondents actually don practice. Second, the survey instrument mayot be sensitive enough to reveal the actual orore subtle factors that drive physician behav-
or. Third, opinions of respondents as expressedn any survey will incorporate and reflect bothactual knowledge and inherent biases. Finally,ttitudes of respondents may be different fromhose of nonrespondents.
In summary, we believe these survey resultsrovide new data that define current Canadianxpert opinion, for which there is currently noetter evidence-based information available. Be-ause most Canadian nephrologists work in highlyeveloped CKD clinics, data from this survey
hould inform nephrologists and funding deci-
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MENDELSSOHN, TOFFELMIRE, AND LEVIN284
ion makers in other jurisdictions about the mer-ts and problems associated with MDT-basedKD care and may help shape the agenda forefining areas for future empirical research.
REFERENCES1. NIH Consensus Statement: Morbidity and mortality of
ialysis. Ann Intern Med 121:62-70, 19942. Levin A, Lewis M, Mortiboy P, et al: Multidisciplinary
redialysis programs: Quantification and limitations of theirmpact on patient outcomes in two Canadian settings. Am Jidney Dis 29:533-540, 19973. Goldstein M, Yassa T, Dacouris N, McFarlane P:ultidisciplinary predialysis care and morbidity and mortal-
ty of patients on dialysis. Am J Kidney Dis 44:706-714,0044. Curtis BM, Ravani P, Malberti F, et al: The short- and
ong-term impact of multi-disciplinary clinics in addition totandard nephrology care on patient outcomes. Nephrol Dialransplant 20:147-154, 20055. Hollomby DJ: Canadian Society of Nephrology Physi-
ian Resources Planning Report. 19986. Pereira BJ, Burkart JM, Parker TF III: Strategies for
nfluencing outcomes in pre-ESRD and ESRD patients.m J Kidney Dis 32:S2-S4, 1998 (suppl 4)7. Obrador GT, Pereira BJ: Early referral to the nephrolo-
ist and timely initiation of renal replacement therapy: Aaradigm shift in the management of patients with chronicenal failure. Am J Kidney Dis 31:398-417, 1998
8. Curtis BM, Ravani P, Kennett F, Taylor PA, Djurdev O,evin A: The short and long term impact of multidisci-linary clinics in addition to standard nephrology care onatient outcomes. Nephrol Dial Transplant 20:147-154, 2005
9. Mendelssohn DC: Coping with the CKD epidemic:he promise of multidisciplinary team-based care. Nephrolial Transplant 20:10-12, 200510. Moss AH: Shared decision-making in dialysis: The
ew RPA/ASN guideline on appropriate initiation and with-rawal of treatment. Am J Kidney Dis 37:1081-1091, 200111. Fine A, Fontaine B, Kraushar MM, Rich BR: Neph-
ologists should voluntarily divulge survival data to poten-ial dialysis patients: A questionnaire study. Perit Dial Int5:269-273, 200512. Mendelssohn DC: Both sides now: Disclosure of
rognosis on dialysis. Perit Dial Int 25:238-239, 200513. Arora P, Obrador GT, Ruthazer R, et al: Prevalence,
redictors, and consequences of late nephrology referral at a
ertiary care center. J Am Soc Nephrol 10:1281-1286, 1999 p14. Campbell JD, Ewigman B, Hosokawa M, Van StoneC: The timing of referral of patients with end stage renalisease. Dial Transplant 18:660-668, 198915. Schmidt RJ, Domico JR, Sorkin MI, Hobbs G: Early
eferral and its impact on emergent first dialyses, health careosts, and outcome. Am J Kidney Dis 32:278-283, 1998
16. Sesso R, Belasco AG: Late diagnosis of chronic renalailure and mortality on maintenance dialysis. Nephrol Dialransplant 11:2417-2420, 199617. Winkelmayer WC, Glynn RJ, Levin R, Owen WF Jr,
vorn J: Determinants of delayed nephrologist referral inatients with chronic kidney disease. Am J Kidney Dis8:1178-1184, 200118. Winkelmayer WC, Glynn RJ, Levin R, Owen W Jr,
vorn J: Late referral and modality choice in end-stage renalisease. Kidney Int 60:1547-1554, 200119. Huisman RM: The deadly risk of late referral. Neph-
ol Dial Transplant 19:2175-2180, 200420. Levin A: Consequences of late referral on patient
utcomes. Nephrol Dial Transplant 15:S8-S13, 2000 (suppl)21. Nissenson AR, Collins AJ, Hurley J, Petersen H,
ereira BJ, Steinberg EP: Opportunities for improving theare of patients with chronic renal insufficiency: Currentractice patterns. J Am Soc Nephrol 12:1713-1720, 200122. Pereira BJ: Optimization of pre-ESRD care: The key
o improved dialysis outcomes. Kidney Int 57:351-365,00023. Pereira BJ: Overcoming barriers to the early detec-
ion and treatment of chronic kidney disease and improvingutcomes for end-stage renal disease. Am J Manage Care:S122-S135, 2002 (suppl 4)24. Valderrabano F, Golper T, Muirhead N, Ritz E, Levin
: Chronic kidney disease: Why is current managementncoordinated and suboptimal? Nephrol Dial Transplant6:S61-S64, 2001 (suppl 7)25. Mendelssohn DC, Barrett BJ, Brownscombe LM, et
l: Elevated levels of serum creatinine: Recommendationsor management and referral. CMAJ 161:413-417, 1999
26. McLaughlin K, Manns B, Culleton B, Donaldson C,aub K: An economic evaluation of early versus late referralf patients with progressive renal insufficiency. Am J Kid-ey Dis 38:1122-1128, 200127. Smith DH, Gullion CM, Nichols G, Keith DS,
rown JB: Cost of medical care for chronic kidneyisease and comorbidity among enrollees in a large HMO
opulation. J Am Soc Nephrol 15:1300-1306, 2004