Familiarity, beliefs, and perceived barriers to practicing guidelines for non-diabetic CKD among nephrology specialists and primary care physicians

Integrated healthcare featured collaboration between nephrology specialists and primary healthcare physicians and may help in addressing fragmented service provided by different levels of hospitals separately, which is typical in China. Yinzhou district of Ningbo city initiated an integrated healthcare program in 2021 by leveraging tertiary hospitals and primary care clinics to screen patients with chronic kidney disease (CKD), establish dual referring system and improve ability to manage patients with CKD in primary healthcare physicians. In this study, we aimed to survey the familiarity, beliefs and perceived barriers to practicing Kidney Disease: Improving Global Outcomes guidelines for management of non-diabetic CKD among physicians within the program.

We performed a cross-sectional survey regarding CKD guideline familiarity of active physicians in terms of diagnosis, treatment options, self-reported practice behaviors and perceived barriers for implementation of the guideline. A vignette of a 57 years old women with hypertension but without diabetes and cardiovascular diseases and an estimated glomerular filtration rate (eGFR) of 50 ml/min/1.73m2 was used to solicit questions. Totally, 127 nephrology specialists and primary healthcare physicians were involved in the integrated healthcare program. We sent invitation of an online questionnaire directly to the candidates through the instant chat app of Wechat. The invitation was sent up to 3 times with one week apart between adjacent two invitations until the candidates finished filling the questionnaire. The participants could scan a QR code to enter the questionnaire. Records of questionnaire submitted within < 2 minutes were dropped.

Totally, 51 participants submitted the questionnaire. After deleting two records with too short working time, those of 8 nephrology specialists, 17 physicians affiliated in town or street-based primary healthcare centers and 21 in community or village-based primary healthcare clinics were analyzed. The median time of practicing clinical medicine of them was more than 10 years. They encountered respective 25, 10 and 6 patients with CKD in outpatients per week on average. Almost all participants agreed that testing serum creatinine, uACR and/or dipstick urinary protein was useful regarding management of CKD (Table). However, only 62.5% of nephrology specialties, 26.6% of physicians in primary healthcare center and 15.4% in primary healthcare clinics could correctly assign relevant eGFR and uACR categories (“heat map”) as having CKD. Screening for uACR at least once a year and prescription of renin angiotensin system inhibitors (RASi) and statins were common practice, while prescription of sodium-dependent glucose transporters 2 inhibitor (SGLT2i) and combined use of SGLT2i and RASi was less common (Table). The top barrier for screening uACR for patients with CKD was the unacceptance of patients reported by 51.0% and 42.6% of physicians regarding patients with eGFR ≥ 60 and <60 ml/min/1.73m2, respectively. The top barriers for prescription of RASi included fear of side effects (34/43 respondents) and reluctance of changing current prescription (18/41 respondents). Similar barriers were found for prescribing SGLT2i (fear of side effects: 31/39 respondents; reluctance of changing current prescription: 14/39 respondents). The solely important barrier for prescribing statins was fear of side effects (37/42 respondents).

Physicians in an integrated healthcare program generally accepted the recommendation for management of CKD in guideline, but familiarity to the disease definition, raising the awareness of patients and ability to handle side effects due to use of RASi and SGLT2i still needs to enhance.