Journal Article

Exploration of the difference in incidence of renal replacement therapy in elderly patients in Flanders and the Netherlands—a comparison of referral policy

Annemieke Visser, Patricia Sunaert, Casper F.M. Franssen, Wim Van Biesen, Sijmen A. Reijneveld, Kitty J. Jager, Paul E. de Jong, Gerbrand J. Izaks, Geke J. Dijkstra and Ron T. Gansevoort

in Nephrology Dialysis Transplantation

Published on behalf of European Renal Association - European Dialysis and Transplant Assoc

Volume 27, issue 1, pages 338-344
Published in print January 2012 | ISSN: 0931-0509
Published online July 2011 | e-ISSN: 1460-2385 | DOI:
Exploration of the difference in incidence of renal replacement therapy in elderly patients in Flanders and the Netherlands—a comparison of referral policy

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The incidence of renal replacement therapy (RRT) among patients aged ≥65 years is much higher in Flanders, the Dutch speaking region of Belgium, than in the Netherlands. We studied whether differences in referral policy to nephrologists by primary care physicians (PCPs) and specialists between Flanders and the Netherlands may play a role.


A vignette study was performed among 329 PCPs and 96 specialists in Flanders and compared to the vignette study that was conducted among 209 PCPs and 162 specialists in the Netherlands. Physicians were offered six vignettes concerning case reports of patients with chronic kidney disease and varying co-morbidities or social circumstances. Each vignette was presented for a 65- and an 80-year-old patient. Physicians were asked about the likelihood of referral of the patients in the given circumstances. Univariate and logistic regression analyses were performed to identify whether country affected the likelihood of referral.


Univariate analyses showed that the percentage of PCPs who would probably or definitely refer a 65- or an 80-year-old patient with less severe co-morbidity was significantly (P ≤ 0.001) higher in the Netherlands than in Flanders. However, the likelihood of referral of PCPs-concerning patients with more severe co-morbidity did not differ significantly. Specialists in Flanders did not differ in the likelihood to refer patients from that of specialists in the Netherlands. Logistic regression analysis showed that country (higher referral in the Netherlands) was an important predictor for the referral of PCPs, and this was especially the case for patients with less severe co-morbidity. These patterns persisted, even after controlling for other possible predictors as physicians’ age, gender, religion and years in practice.


This study suggests that the lower RRT incidence in the Netherlands cannot be explained by a more restrictive referral policy among physicians in the Netherlands. The data suggested that the latter group had a similar or even more liberal attitude to the referral of older patients than physicians in Flanders.

Keywords: chronic kidney disease; co-morbidity; non-nephrology specialists; older patients; primary care physicians; referral behaviour

Journal Article.  3693 words.  Illustrated.

Subjects: Nephrology

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