CLINICAL UNCERTAINTY AND RISK AVERSION ARE ASSOCIATED WITH PRIMARY CARE PROVIDER REFERRAL OF PATIENTS WITH SEVERE KIDNEY DISEASE TO NEPHROLOGY

Purpose: To identify the independent associations of primary care provider (PCP) characteristics with the decision to refer older patients with advanced chronic kidney disease (CKD) to a nephrologist

Method: A survey using hypothetical clinical vignettes was presented to members of two regional practice-based networks of PCPs in 2009-2010.  PCPs provided personal (age, gender, race, medical specialty, foreign medical school graduate) and practice characteristics (community setting, estimated percent of patients over age 65 in practice, and estimated number of referrals to nephrology made in the last year), and completed the Reaction to Uncertainty (RTU) questionnaire, which included 4 sub-scales: 1) anxiety about uncertainty, 2) concern about bad outcomes, 3) reluctance to disclose uncertainty to patients, and 4) reluctance to disclose uncertainty to other physicians.  They also answered a question about risk aversion (Are you more, equally, or less likely to take risks than other people your age?).  The primary outcome was the decision to refer (or not) hypothetical patients with guideline-defined severe CKD.  The vignettes dichotomously varied 6 patient characteristics and 8 vignettes were randomly distributed to each PCP in a blocked factorial design.  Logistic regression analysis was performed to assess the independent associations.   

Result: Data from 632 referral decisions by 81 PCPs (response rate 40%) were analyzed. PCPs are largely family practice physicians (87%), white (88%), and male (76%), with a mean age of 50.   In adjusted multivariate logistic regression analysis, risk aversion (OR 2.04[1.42 - 2.91]), greater anxiety about uncertainty (OR 1.27[1.16 - 1.39]), and reluctance to disclose uncertainty to other physicians (OR 1.21[1.07 - 1.37]) were independently associated with the referral.  Greater concern about bad outcomes was associated with non-referral (OR 0.83[0.76 - 0.91]).  Female PCP gender (OR 2.04[1.09 to 3.79]) was also associated with greater likelihood of referral while older patient age (OR 0.45[0.31-0.67]) and a diagnosis of dementia (OR 0.35[0.24-0.52]) were associated with non-referral. Analysis was adjusted for PCP demographic characteristics, practice demographics, awareness of practice guidelines for CKD, and patient characteristics.

Conclusion: PCP reactions to uncertainty and risk-aversion significantly predict referral decisions for severe kidney disease, even after adjusting for demographic characteristics known to be associated with referral decisions.  These important, but previously unrecognized, PCP characteristics are potential targets for behavioral interventions to improve guideline adherence and clinical decision making.