Clinical and Financial Impacts of Late Referral in Patients With Chronic Kidney Disease: A Narrative Review

TL;DR

Late referral to nephrology for chronic kidney disease worsens outcomes and increases healthcare costs, but early intervention can help reduce these issues.

Contribution

This review identifies patient, physician, and system factors causing late referrals and proposes strategies to reduce CKD care costs.

Findings

Late referral rates to nephrology range from 30% to 52% globally.

Late referrals increase CKD management costs due to higher morbidity and need for renal replacement therapy.

Early referral and system improvements like standardized guidelines can improve outcomes and reduce costs.

Abstract

Chronic kidney disease (CKD) is a worldwide burden on healthcare systems. As the disease severity progresses, CKD patients are at high risk of morbidity, mortality, and renal replacement therapy. The cost of care for these conditions is substantially high and increases as the disease progresses. Early referral to nephrology and appropriate management can potentially improve outcomes and reduce costs if implemented efficiently. This review aimed to identify the causes of late referral to nephrology specialists and their impact on CKD costs. Proposed implications and recommended actions were included to address late referrals and ultimately reduce care costs. A thorough literature review was conducted using MEDLINE, Embase, and Scopus databases, covering studies published up to December 2024 on the causes of late referral to nephrology and its impact on the costs of CKD care. The causes of late referral are classified into (i) patient-related, (ii) physician-related, and (iii) health system-related factors. The financial burden of CKD is discussed, including the overall costs of CKD management and the impact of late referral on costs. The review included peer-reviewed articles discussing the causes and outcomes of late referral to nephrology specialists. Pediatric studies, acute kidney injury (AKI) diagnosis, or societal cost studies were excluded. Late referral rates to nephrology specialists remain high worldwide, ranging from 30% to 52%. Multiple causes of late referrals have been identified. Patient-related factors included low awareness, socioeconomic barriers, comorbidities, and psychological factors. Physician-related factors included the lack of familiarity among non-nephrology specialists with the indications for nephrology care or referral. Healthcare system-related factors included lack of referral guidelines, limited access to nephrology specialists, insurance and coverage barriers, and poor coordination between primary care physicians and nephrologists. In addition, this review demonstrated the significant financial burden of CKD worldwide, and the financial impact of late referral further increases the costs of CKD care. Serious measures must be undertaken to ensure that referrals are made promptly when outcomes can be modified. In conclusion, early referral of patients with CKD to nephrology specialists could improve clinical outcomes and reduce the financial burden on healthcare systems. Standardized referral guidelines, unified screening tools, electronic medical records, and telemedicine could enhance early nephrology consultation.

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