Nephrologist referrals of older patients with chronic kidney disease in Singapore: a cross-sectional study

Background: Chronic kidney disease (CKD) is common in the older population. By 2035, approximately one-quarter of Singapore residents are expected to have CKD. Many of these patients are not referred to nephrologists. Aim: To compare the characteristics of older patients (aged >= 65 years) with CKD stage >= 3B in the referral and non-referral groups. Design & settings: A cross-sectional study in the primary care organisation National University Polyclinics (NUP), Singapore. Method: Retrospective data were extracted from the electronic health records of patients with CKD (aged >= 65 years) with CKD stage >= 3B. Results: From 1 January-31 December 2018, a total of 1536 patients aged >= 65 years were diagnosed with CKD stage >= 3B (non-referral group = 1179 versus referral group = 357). The mean patient age in the non-referral group (78.4 years) was older than that in the referral group (75.9 years) (P<0.001). Indian older patients were referred more compared with their Chinese counterparts (P = 0.008). The non-referral group was prescribed significantly less fibrate, statins, insulin, sulfonylureas, dipeptidyl peptidase -4 (DPP4) inhibitors, and antiplatelet than the referral group (P<0.05), but only the difference in fibrates remained significant on subsequent multivariate analysis. Conclusion: This study demonstrates that there is a considerable number of older patients with CKD exclusively managed in the primary care setting (n = 1179) and that referrals primarily depend on demographic factors, namely age and ethnic group, rather than medical determinants of CKD severity or case complexity.