Fewer than half (45%) of surveyed internal medicine residents perceived proteinuria (1 g/g), hyperkalemia (26%), anemia of CKD (28%), and bone and mineral disorder of CKD (45%) to be indications for referral to nephrology.
The majority of surveyed internal medicine residents believed fast decline of GFR (79%), uncontrolled hypertension (65%), and GFR <30 ml/min/1.73 m² (90%) to be indications for referral to nephrology.
Surveyed residents with CKD clinic experience were more likely to identify fast decline in GFR as an indication for referral and less likely to identify GFR <30 ml/min/1.73 m² as an indication for referral than those without CKD clinic experience (P <0.05 for both).
The majority of surveyed internal medicine residents (59%) selected GFR 15-30 ml/min/1.73 m² as the level of GFR at which referral to nephrology for start of renal replacement therapy is warranted.
Chart Explanation: Fewer than half (44.7%) of the residents perceived proteinuria (1 g/g) to be an indication for referral to nephrology. The majority (78.9%) believed fast decline of GFR warranted referral. Uncontrolled hypertension was deemed by many to be an important indication for nephrology referral (64.5%), as was GFR <30 ml/min/1.73 m² (89.6%). However, few residents noted hyperkalemia (26.1%), anemia of CKD (28.0%), and bone and mineral disorder of CKD (44.9%) to be indications for referral.
In October-November 2007, Agrawal et al. conducted a national online survey of 479 internal medicine residents from 75 residency programs identified via their fellowship program directors. Responses may be biased by residency program or online access.
"In the period of October to November 2007, Agrawal et al. (2009) conducted a national online survey of 479 internal medicine residents from 75 residency programs [166 post-graduate year 1 (PGY 1), 187 PGY 2 and 126 PGY 3 residents] identified via their fellowship program directors. The response of the residents depended on both the program director forwarding the link to the online survey to the program residents and the residents themselves responding to the survey, so a usual response rate could not be calculated. However, a total of 397 program directors were provided a link to the survey, representing 22,009 eligible internal medicine residents in training.
The survey consisted of four clinical vignettes assessing nephrology referral patterns. In the first clinical vignette, a 52-year-old patient with diabetic kidney disease (GFR 70 ml/min/1.73 m²) and microalbuminuria (58 mg albumin/g creatinine) presents for 1 year follow-up and is found to have worsening GFR (50 ml/min/1.73 m²) and proteinuria (> 1 g/g). The second vignette described a 53-year-old patient with nondiabetic CKD (GFR 29 ml/min/1.73 m² and uncontrolled hypertension despite taking four antihypertensives, including an angiotensin-converting enzyme inhibitor and a potassium-sparing diuretic) and hyperkalemia. The final two clinical vignettes described patients with anemia and bone and mineral disorders of CKD stage 3 (GFR 30-59 ml/min/1.73 m²). Finally, residents were asked to choose the range of GFR at which they would consult a nephrologist for dialysis and vascular access. CKD clinic experience was defined as an answer of yes to the question “Do you see patients in a Chronic Kidney Disease Clinic?.”
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| Field | Data |
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| Description of Measure | Referral of CKD patients among physicians in training |
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| Data Source | National cross-sectional survey of internal medicine residents in 2007 |
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| Type of Data Source | Private |
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| Data Set | Survey results |
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| Health Care System Data | No |
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| Regional or National? | National |
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| Demographic Group | 56.8% had international medical training; 42.6% female; 44.9% from university-based residency |
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| Numerator | Respondents identifying each clinical factor as an indication for referral to nephrology |
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| Denominator | All respondents who were residents and had complete questionnaires |
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| Proteinuria | 1g/g |
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| Primary Data Source Indicator | Proportion of residents who correctly identified each clinical factor as an indication for referral to nephrology |
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| Primary Indicator Method of Measurement | Survey |
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| Frequency of Measurement (Primary) | Once (cross-sectional) |
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| U.S. Region Covered by Primary Variable | 75 U.S. internal medicine programs; 27 (36%) in the Northeast, 23 (31% in the Midwest), 14 (19%) in the South and 11 (14%) in the West |
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| Period Currently Available | 2007 |
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| Pending Data | Unknown |
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| Additional Data Items of Interest | CKD clinic experience |
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| Limitations of Indicator | Likely survey response bias, no data on nonresponders; most residents were from Midwest and Northeast; usual response rate could not be calculated, although 75/479 directors and 479/22,009 residents were represented in the final sample; self-reported CKD clinic experience |
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| Analytical Considerations | Kruskal-Wallis one-way ANOVA to assess trends across PGY |
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References and Sources:
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Agrawal V, Ghosh AK, Barnes MA, McCullough PA. Perception of indications for nephrology referral among internal medicine residents: A national online survey. Clin. J. Am. Soc. Nephrol. 2009;4(2):323-328.