Detection and Management of CKD in Primary Care: Barriers and Enablers

The increasing prevalence of chronic kidney disease (CKD) presents a worldwide health concern. Results of the Global Burden of Disease Study demonstrated that in 2015, 1.2 million deaths were related to kidney failure, an increase of 32% from 2005. In higher income countries, 2% to 3% of healthcare budgets are related to end-stage renal disease (ESRD). Patients with declining kidney function face increased risk of cardiovascular events and death, contributing significant costs to healthcare expenditures.

In patients with CKD, progression to ESRD can be slowed or prevented with early identification and effective management. Many patients with risk factors for CKD or early stages of CKD are treated in primary care. Elizabeth P. Neale, PhD, and colleagues at the School of Medicine, Wollongong, NSW, Australia, conducted a systematic review to examine the barriers and enablers to the diagnosis and management of CKD in primary care. Results were reported online in BMC Nephrology [doi.org/10.1186/s12882-020-01731-x].

The researchers searched the databases Medline (EBSCO), PubMed, Cochrane, CENTRAL, CINAHL (EBSCO), and Joanna Briggs Institute Evidence Based Practice (OVID) to identify relevant articles. The search was conducted initially in April 2018 and then updated on August 27, 2019. Eligible studies reported qualitative data on the barriers and/or enablers to detection and/or management of CKD stages 1-5 in adults >18 years of age within primary care.

Barriers and/or enablers reported in each study were identified, classified into themes, and categorized according to the Theoretical Domains Framework. The framework consists of 12 theoretical domains related to behavior change. In addition to the published domains, the researchers included an additional domain, perceptions of patients.

The original and updated searches identified a total of 20,840 results. Following removal of duplicates, 14,448 results were screened by title and abstract. Full text review was conducted on 349 potentially relevant articles; 22 articles describing 20 studies were included in the final review.

The designs of the 20 studies were interviews (n=12), focus groups (n=6), and surveys with open-ended responses (n=2). The studies represented participation from general practitioners, nurses, practice managers, pharmacists, and medical assistants, and were conducted in the United Kingdom, the United States, Australia, Canada, and the Netherlands.

The barriers to detection and management of CKD in primary care identified in the review fell into seven domains on the Theoretical Domains Framework: beliefs about capabilities; beliefs about consequences; environmental context and resources; knowledge; perceptions about patients; social influences; and social/professional role and identity. The enablers to the diagnosis and management of CKD in primary care fell into six domains: beliefs about capabilities; beliefs about consequences; environmental context and resources; knowledge; social influences; and social/professional role and identity.

The most commonly reported barriers related to detection and management of CKD in primary care fell into the environmental context and resources domain (n=16 studies). Overall, the most common barriers identified were lack of time (n=13 studies), fear of delivering a CKD diagnosis (n=10 studies), and dissatisfaction with CKD guidelines (n=10 studies).

The most commonly reported enablers to the diagnosis and management of CKD in primary care also fell in the environmental context and resources domain (n=14 studies). Primary care physicians reported that technological improvements enabled them to identify and manage CKD. They highlighted shared electronic medical records that could facilitate collaboration among healthcare providers as well as software programs that automatically calculate estimated glomerular filtration rate.

Other enablers reported were the availability of patient education resources, funding for screening and management initiatives, clear referral pathways to specialist care including guidelines on when to refer, and improved access to support services.

Limitations to the study cited by the authors included the small sample sizes in the included studies, limiting the generalizability of the findings; the studies coming from multiple countries with varied healthcare systems; the inability to compare findings from between countries; and all of the studies being reported in the English language.

In conclusion, the researchers said, “This systematic review identified a number of barriers and enablers which primary care physicians face when identifying and managing CKD. Themes relating to environmental context and resources, beliefs about consequences, and knowledge were the most commonly reported barriers, specifically a lack of time, anxiety communicating a diagnosis of CKD, and a dissatisfaction with current CKD management guidelines. The presence of supportive technology within practices was the most commonly described enabler, followed by a collaborative relationship between members of the primary healthcare and nephrology team. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently comorbid nature of CKD. Enhanced collaboration between primary care physicians and nephrology services may also support primary care physicians when diagnosing CKD in primary care, and facilitate improved patient self-management.”

Takeaway Points

  1. Progression of chronic kidney disease CKD can be slowed with early detection and management of patients; many patients with risk factors for CKD are treated in primary care. Researchers performed a systematic literature review to identify the barriers and enablers to detection and management of CKD in primary care.
  2. The most commonly reported barriers fell in the environmental context and resources domain, including lack of time, fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines.
  3. The most commonly reported enablers were the availability of supportive technology and the presence of a collaborative relationship among members of the healthcare team.