Q&A: Removing barriers that hinder PCPs from diagnosing, treating, CKD

C. John Sperati

Primary care physicians who were interviewed by researchers identified several barriers at the patient, physician and systems level that impede management of chronic kidney disease in primary care, according to findings published in PLoS One.

According to the researchers, the prevalence of chronic kidney disease (CKD) in the United States was 14% in 2015 to 2016. In addition, deaths from the disease worldwide skyrocketed 82% in the past 2 decades.

Despite the increased occurrence of CKD, its “complexity” and the “lack of comfort” some primary care physicians feel about the disease may keep them from accepting patients with the condition, C. John Sperati, MD, MHS, director of Johns Hopkins University School of Medicine's nephrology fellowship training program, told Healio Primary Care.

According to Sperati, who was one of the authors of the PLoS One study, each nephrology provider has more than 2,000 patients, suggesting that PCPs may have to overcome those feelings and other obstacles, including a lack of available tools to facilitate diagnosis and treatment. He discussed ways PCPs can overcome these barriers. – by Janel Miller

Q: What are some of the ways that PCPs can recogniz e and diagnos e CKD in its earlier stages?

A: There are well-validated recommendations from the National Kidney Foundation and American Diabetes Association that discuss the various screening components for CKD; specifically, calculating estimated glomerular filtration rate, obtaining a urinalysis and measuring urine albumin to creatinine ratios. That rate and ratio form the basis of CKD staging.

PCPs also should be attentive to those at particular risk for CKD. These include African Americans, Hispanics and patients with hypertension, diabetes, family history of kidney disease, HIV, viral hepatitis, autoimmune disease and sickle cell disease, among others.

Q: How can PCPs overcome the barriers to discussing, recognizing and treating the barriers you identified?

A: PCPs could consider broaching the topic of CKD with patients several times while he or she is in the early stages of the disease, when the stakes are lower. This allows the issue to be revisited periodically over time, so patients have more opportunity to learn about CKD and to be proactive in protecting the health of their kidneys. PCPs could direct patients to the academic medical centers and large private nephrology practices that offer CKD education classes for patients.

In addition, the National Kidney Foundation published a nice algorithm in 2016 for the detection and management of CKD that provides actionable information for PCPs in the American Journal of Medicine. This same group maintains CKDinform, a free, web-based collection of evidence-based resources for PCPs. Since appointment times are short, and much of the work done by physicians is not compensated, all physicians, not just PCPs, need to learn how to best leverage technology and online resources to facilitate patient education and ongoing disease management.

System-level barriers are much more difficult to overcome. In reality, this requires a collaborative commitment on the part of insurers, the federal government, health systems, and health care providers to change how health care is delivered and reimbursed. It also means nephrologists need to better about collaborating with PCPs in the co-management of patients with CKD. HHS’ announcement this past July of the Advancing American Kidney Health initiative may also help motivate the relevant parties commit to systems-level changes that facilitate optimal care of patients with CKD.

Q: What else can we do to improve CKD knowledge and support among the primary care community?

A: PCPs may find the use of collaborative practice agreements between PCPs and nephrologists and the use of e-consults to improve CKD knowledge and support a helpful tool.

For more information:

National Kidney Foundation. CKD inform. https://www.kidney.org/CKDinform. Accessed Sept. 30, 2019.

Vassalotti JA, et. al. Am J Med. 2016;doi:10.1016/j.amjmed.2015.08.025.

Reference:

Sperati CJ, et al. PLoS One. 2019;doi:10.1371/journal.pone.0221325.

Disclosures: Sperati reports no relevant financial disclosures.