Most of SG’s older CKD patients managed in primary care

In Singapore, many older patients with chronic kidney disease (CKD) are managed exclusively in the primary care setting, according to a new study. Referrals seem to be more dependent on a patient’s demographic factors rather than medical determinants.

“This study highlights that family physicians at [the National University Polyclinics] managed 77 percent of the total elderly CKD patients with stage 3B, 4, and 5 diseases,” the researchers said. “This reflects a vital role of family physicians in managing the elderly with severe CKD.”

The present retrospective study used electronic health data from 1,536 older patients with stage 3B CKD (aged ≥65 years). Only 357 patients were eventually referred by their family physicians to nephrologists; the majority (n=1,179) received medical management in the primary care setting. [BJGP Open 2022;doi:10.3399/BJGPO.2021.0155]

Bivariate analysis revealed that nonreferral patients were significantly older than those who eventually saw nephrologists (mean age, 78.3 vs 75.9 years; p<0.001). There was a significantly higher proportion of patients aged ≥90 years who were not referred to specialists (7.12 percent vs 3.36 percent; p<0.001).

Age remained a significant correlate of referral regardless of whether it was treated as a categorical or continuous variable (p<0.001 for both).

Chi-square analysis revealed that ethnicity was also significantly associated with referral (p=0.017). Patients of Indian (5.88 percent vs 4.07 percent) and Malay (20.17 percent and 17.30 percent) ethnicities, for instance, were more likely to be referred to specialists than not, while the opposite was true for Chinese patients (70.03 percent vs 76.93 percent).

Similarly, the use of the following medications differed significantly between referral and nonreferral patients: fibrates, statins, insulin, sulfonylureas, dipeptidyl peptidase-4, and antiplatelets.

Medical considerations, on the other hand, did not significantly influence referral decision. Bivariate analysis showed that referral and nonreferral groups were comparable in terms of CKD severity and comorbidities.

Logistic regression analysis confirmed the lack of association between CKD severity and the likelihood of specialist referral. In the fully adjusted model, age remained a significant determinant of referral, with patients aged 80–84 years (odds ratio [OR], 0.47, 95 percent confidence interval [CI], 0.30–0.73; p<0.001), 85–89 years (OR, 0.56, 95 percent CI, 0.34–0.91; p=0.02), and ≥90 years (OR, 0.48, 95 percent CI, 0.23–0.99; p=0.046) being less likely to be referred to a nephrologist.

In contrast, patients of Indian ethnicity were more than twice as likely as Chinese counterparts to see a specialist (OR, 2.07, 95 percent CI, 1.16–3.70; p=0.014).

“This study highlights the need to review the referral process in this diverse group of patients and to better understand the role of sociodemographic factors in this context,” the researchers said.

“We recommend multidisciplinary collaboration between family physicians and nephrologists to refine the referral criteria to detect patients who truly need early referrals to nephrologists and to develop guidelines to optimize primary care management and monitoring of CKD patients, especially for those who are not referred and treated conservatively,” they added.