Healthcare professionals’ perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics
BMC Health Services Research volume 22, Article number: 560 (2022)
The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals’ (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs’ perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore.
In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2.
Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries.
The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.
Chronic kidney disease (CKD), with a worldwide prevalence of 11%-13%, is an increasingly common public health problem . CKD is associated with premature cardiovascular disease, all-cause mortality, and high risk of progression to end-stage kidney disease (ESKD) requiring costly kidney replacement therapy- dialysis or kidney transplant [2, 3]. CKD is one of the steepest rising causes of death globally, including in Singapore, which ranks fifth worse in incident ESKD worldwide [4, 5].
Kidney Disease Improving Global Outcome (KDIGO) classifies patients with CKD into categories according to level of estimated glomerular filtration rate (eGFR) and albuminuria based on the risk of progression to ESKD . Most patients with CKD are usually asymptomatic until the disease becomes advanced, i.e., eGFR < 30 ml/min/1.73m2. Primary care is the first point of contact of most patients with early stages of CKD with the health system worldwide and in Singapore. Prompt institution of non-pharmacologic and pharmacologic therapy at early stages of CKD can preserve kidney function and prevent CVD . However, serious gaps exist in clinical practices with regards to management of CKD. In an analysis of 20,538 individuals in the US, 50% of patients with proteinuric CKD were not receiving the recommended renin–angiotensin–aldosterone system (RAAS) blockers . Likewise in Singapore, less than 50% of patients with diabetes and CKD had blood pressure control to < 140/90 mm Hg, and less than 50% had glycated hemoglobin of < 7% .
Existing literature suggests impediments to CKD management in primary care exists at multiple levels . Patient-reported challenges and perceptions on CKD management are well documented . However, there is limited understanding on the challenges and opportunities to enhance CKD management from perspectives of HCPs involved in direct care of patients with CKD. Including HCPs from primary care and nephrologists, key stakeholders in the CKD care spectrum, will maximize the diversity of perceptions and opinions on CKD management. Underpinned by the Theoretical Domains Framework (TDF), the study aimed to explore HCPs’ perspectives on facilitators of and barriers to CKD management in primary care in Singapore.
Study setting and design
Primary healthcare for the multi-ethnic population in Singapore is delivered as a fee-for-service via a network of public sector primary care polyclinics and private general practitioner clinics, the former providing care to the majority of patients with chronic diseases . The public polyclinics are well equipped “one-stop” centers and offer comprehensive range of health care services at markedly subsidized rates. Primary care polyclinic model includes referrals to the specialists at the affiliated hospitals for additional evaluation and risk assessment for chronic conditions (eg CKD, cardiovascular diseases). After specialist evaluation patients are often referred back to polyclinics for further management with recommendations from specialists, and often patients are co-managed by primary care physicians with periodic 6-monthly or yearly visits to the specialists.
The study set in SingHealth, a large healthcare cluster with a network of nine public polyclinics and three referral hospitals included a sampling frame of multidisciplinary stakeholders (physicians, nurses, and pharmacist) from three polyclinics with experience of managing patients with CKD in the past year, and nephrologists from the specialist outpatient clinic (SOC) at one affiliated referral hospital. In order to maximize the diversity in views and experiences, participants were recruited in terms of years in practice and practice location. A total of 21 potential participants were approached with an invitation letter through their respective department heads, and except for one participant who did not agree due to time constraints, all others accepted to attend the interview. Participants were contacted by the study coordinator thorough email and interviews were scheduled.
We used the Theoretical Domains Framework (TDF) version 2 to guide the interviews and analyze data. TDF is a single framework that synthesizes 128 constructs from 33 behavior and behavioral change theories clustered into 14 domains [13, 14]. TDF has capacity to elicit a comprehensive set of beliefs and is informative regarding the potential mediators of behavior change. Our interview probes adapted the TDF framework to discern barriers and facilitators regarding HCP’s perception to eventually develop effective interventions to support optimal CKD management in primary care .
In-depth interviews were conducted on a purposive sample of 20 participants comprising 13 physicians, 4 nephrologists, 2 nurses and 1 pharmacist. A semi-structured interview guide with open-ended questions developed by qualitative research and implementation science experts explored participants’ perceived knowledge and skills in CKD management, professional role, confidence in managing CKD, ability to reveal CKD diagnosis, communication capabilities, barriers and facilitators to CKD management, decision process for referrals and usefulness of decision-support tools. Pre-testing was undertaken on three individuals and their responses was used to refine the interview questions. All interviews took place in private consultation rooms in the healthcare facility to ensure participant comfort and lasted between 30–60 min. The interviews were conducted in English by the research team members (TNC, CR, SY, PM) trained in qualitative methodologies and extensive experience conducting in-depth interviews. The participants had no personal or professional relationship with the interviewers, and this allowed participants to express their opinions freely. Interviews were audio recorded and transcribed verbatim by research team members.
The SingHealth Centralized Institutional Review Board (CIRB) approved the study. Prior to interviews, participants signed a written informed consent for participation, for audio recording of interviews and confidentiality of their responses. All methods were performed in accordance with relevant guidelines and regulations.
Verbatim transcripts of the interviews were reviewed and checked with the audio recordings for accuracy. Two researchers (CR, SJH) independently conducted the data analysis using QSR NVivo 11 software. Data was analyzed using both inductive and deductive methods . At first, the researchers read and re-read the transcripts and familiarized with the data. The thematic analytic process involved coding, repetitive sorting and comparison. Each transcript was open-coded line by line to create code components. The code components were compared and grouped into categories and themes pertaining to facilitators and barriers to CKD management. The categories and themes were subsequently mapped against the relevant domains within the TDF. Domains with overlapping and inter-linked themes that reflected key clinical behaviors and tasks relevant to CKD management were combined to represent meaningful concepts to systematically understand barriers and facilitators. For example, when themes such as knowledge gaps in junior doctors or lack of self-management skills in patients were identified, they were assigned to the TDF domain of ‘knowledge & skills.’ Consensus meetings were held to ensure that themes were mutually exclusive, and that mapping reflected an accurate conceptualization of the TDF domains. Discrepancies were resolved and deviant cases identified. All themes were aligned with the domains within TDF. Thematic saturation was achieved after analyzing 15 transcripts. We anchored the methodology with reference to COREQ . (See additional file 1 COREQ checklist).
In all, 20 participants completed the interviews of which 14 (70%) were females and the mean age was 37.7 years. The participants comprised of 13 (65%) physicians, 4 (20%) nephrologists, 2 (10%), nurses and 1 (5%) pharmacist. The mean years of service was 9.3 years, and 10 (50%) participants had more than 10 years of professional experience. Most participants (90%) managed 31 or more patients with CKD in the past year. Table 1 summarizes the participant characteristics.
HCPs’ perceived barriers and facilitators to CKD management were captured under themes encompassing 12 of the 14 TDF domains. Overall, 24 themes including 11 barriers and 13 facilitators to CKD management emerged and described under relevant TDF domains. Figure 1 illustrates the barriers and facilitators to CKD management conceptualized using the TDF version 2.
Barriers to CKD management
Perceived knowledge and skills
One of the key barriers to CKD management was differential level of competency among physicians, with few openly accepting knowledge and practice gaps on CKD management. Some physicians perceived limited information on CKD management in their reference handbooks and felt challenged due to lack of protocols or clinical practice guidelines similar to diabetes. As a result, physicians felt unprepared, and attributed the shortcomings to lack of CKD training as an important barrier.
“I think, even our new medical officers who are coming in, if I remember correctly, the induction program didn’t cover anything on renal, I think, if I’m not wrong – mainly just hypertension and common things.” Participant 14_Physician.
Several providers discussed the lack of CKD awareness and self-management skills among patients as a barrier to CKD management. Over 50% of patients, especially in earlier stages of CKD, i.e. CKD stage 3, and the majority of elderly, were unaware of their CKD status.
“May be if I have to put a number to it, may be about at least more than 50 percent not aware especially those with milder CKD…like stage 3’’ Participant 06_Physician.
Participants recounted poor health knowledge, variable level of awareness, poor self-management skills with lack of sustained behavioral modifications and issues with medication adherence among patients with CKD that necessitated a more paternalistic approach from physicians. However, few physicians had divergent views and believed that younger patients and individuals with CKD stage 4 were often aware of their condition, and often times fear of dialysis motivated and nudged them to be adherent to management recommendations.
Professional role and identity & beliefs about consequences
HCPs in primary care believed their role was important as the key caregiver for patients with chronic conditions. Although they prioritized managing chronic diseases like diabetes, hypertension, and hyperlipidemia, CKD was not a priority. They felt that since CKD was primarily asymptomatic, it is often neglected during clinical consultations. Perceptions on prioritizing CKD in primary care were mixed. Some respondents perceived CKD was 'not viewed in the same league as diabetes, stroke, or heart attacks'. In contrast, some respondents stressed the need to consider CKD as an essential condition needing more attention in primary care. Nonetheless, physicians expressed that due to competing priorities in a consultation, especially for patients with multiple morbidities, CKD received less attention in primary care.
“It is just that we don’t routinely look into the CKD and our knowledge on treating patients with CKD is really lacking. So therefore, currently we give very little attention to CKD.” Participant 05_Physician.
Belief about capabilities & optimism
Although respondents strongly believed in their capabilities for treating general aspects of CKD, some physicians expressed apprehensions and felt unfamiliar in prescribing higher doses of blood pressure medications, managing hyperkalemia, and advising kidney diet. More often, such precarious situations prompted their referrals to nephrologists.
“I think the most difficult one is when does it come to a point where we need to stop medicines or adjust the renal medicines or the renal doses. For things that, you know, usually when managing protein urea and all that, usually in the outpatient clinic setting, we only have a maximum dose you can give. So, and also, the experience that we have is, I mean, quite limited I would say, so we don’t really increase the medicines although we can.” Participant 01_Physician.
Intentions and goals
With an intention not to cause alarm or create anxiety for patients, many physicians did not proactively bring up CKD during consultations.
“So, most of the time, we’ll pick it up quite early because of the screening, so most of the patients don’t have the CKD. And then when they start, they do get the CKD, maybe, like stage 2, we won’t really alarm them” Participant 14_Physician.
When physicians discussed CKD, it was common to use simple language and ‘lay terms’ like ‘weak kidneys’ but refrained from explaining CKD stages or severity. Participants highlighted that physician–patient communication was not always optimal and led to ineffective CKD diagnosis disclosure. One participant expressed that often patients are astonished when physicians reveal CKD diagnosis.
“They (patients) are very surprised, and they react as if they have not been told before, even though they may have had it for years.” Participant 06_Physician.
Nephrologists expressed concern over the ineffective CKD diagnosis disclosure in primary care citing numerous episodes of patients not comprehending the reason for their renal clinic referral. They also noted the patient’s reluctance for a nephrologist’s review. However, few physicians articulated their desire, intent, and efforts to communicate with patients but were confounded by patient-level challenges of poor CKD knowledge and awareness.
Memory attention and decision process
Polyclinics have standardized criteria for specialist referrals. Nevertheless, physicians expressed limitations in decision-making for specialist referrals due to ‘doubts’, ‘fear of missing out on things’, ‘to be seen early’ and ‘not wanting to wait'.
“So usually, I won’t wait for the patient to be severe and then I refer. But, I usually if it is stage 4, I will definitely offer a referral whether the patient take it themselves after the discussion”. Participant 06_Physician.
Although nephrologists expected most referrals in stage 3b, nevertheless they expressed that the “volume of referrals was tremendous”,. They felt that physicians in primary care were unable to adhere to explicit referral criteria which resulted in inappropriate referrals especially of elderly with mild reduction in eGFR thereby creating a burden on the renal specialist clinics. However, the nephrologists also recounted numerous instances of late referrals.
“It’s (referral) very standard. They have to fit the certain criteria before you can refer here (specialist clinic), so there are some tendencies, so the doctor that really wants to refer even though it doesn’t really fulfil the criteria, just anyhow click on all of them. So sometimes, we do encounter such situations, which is unavoidable. Sometimes they don’t read the criteria properly and they still refer”. Participant 18_Nephrologist.
Environmental context and resources
Environmental context and resources emerged as a key domain influencing CKD management. Participants identified a wide range of organizational factors like short consultation time, suboptimal care coordination and pathways, and lack of resources impeding CKD management. Most respondents expressed short consultation time is a key barrier to managing CKD. Participants found consultation duration of 5–10 min limiting for CKD to go ‘through in detail,’ and the need to address other conditions first, with CKD ‘just be seconded around and forgotten.’ In addition, most respondents perceived time constraints limiting discussions on CKD, often times impeding patient-physician communication.
Most respondents commonly mentioned long waiting time for specialist appointments, fragmentation of care, and obscure medical information exchange between primary care- nephrologists that together ensued suboptimal care coordination for CKD. In addition, almost all respondents complained about the long waiting time, with delays in securing specialist appointments needing a lead time of about 3–6 months to see a kidney specialist.
“I think the referral time for them (patients) to see, the kidney doctor can take a while. I think it [specialist appointment] is very long. I think there was a time it was, waiting time can be 6 months also.” Participant 04_Physician.
Adding to the delay, the system of rotation of physicians in the polyclinics led to fragmentation and lack of continuity of care.
“The one (thing) I wanted to mention was (about) the different doctors. So, that may play a factor because sometimes we are not the same doctor that keeps seeing the patient. So, (firstly), you may not have the doctor-patient relationship to be able to communicate that to the patient.” Participant 14_Physician.
Physicians coordinated specialist referrals and often relied on nephrologist’s feedback to follow-up on treatment recommendations. However, obscure medical information exchange between physicians and specialists had a profound impact on care coordination for CKD. Many participants expressed needing more time to screen through electronic documentation in the information systems for patients with multiple specialist visits. Many respondents narrated incidents of patients losing memos and expressed concerned on the suboptimal documentation and communication between physicians and specialists.
“Even though there is some kind of an electronic documentation it is still not optimal. That memo, that hard copy memo may not get to where it is. Now, do I email? No, I don’t email primary, I have no idea where to email.” Participant 19_Nephrologist.
Primary care did have most essential components for managing CKD. However, few respondents perceived lack of resources. Lack of access to laboratory tests like serum calcium and bicarbonate needed to monitor later stages of CKD, and non-availability of some combination anti-hypertensive agents that patients can potentially have their choices to were disclosed by some physicians. Few respondents desired nutrition counseling for patients with CKD, but the polyclinics were constrained on availability of dieticians and incurring additional costs for patients.
“For dietician we only have one dietician available in Singhealth polyclinic because for dietician there is a charge”. Participant 16_Nurse.
Reinforcement & behavioral regulation
Primary care management of early CKD is of utmost importance. However, some HCPs opined that they were just offering basic care at the polyclinics and not helping patients control their disease optimally. Given the increasing CKD burden, primary care needed to have a greater role in the care for CKD. However, few physicians felt otherwise and were concerned that primary care was not doing enough for CKD.
“I think with the increasing number of patients with CKD, the role is greater and but having said that we usually only manage the very milder cases. The more serious ones, the later stage one we will still refer to the specialist to check. And very often after we refer to the specialist other than doing basic kidney function and all that, I don’t think we do very much to monitor.” Participant 04_Physician.
Facilitators to CKD management
Knowledge and skills of physicians and patients
Most physicians perceived as being competent on procedural knowledge & having the requisite skills for CKD diagnosis having performed annual CKD screening for albuminuria, calculated eGFR for staging CKD, and using RAS blockers for hypertension control. However, to address gaps in knowledge to effectively manage CKD, many respondents desired CKD education and relevant topics to be ‘taught properly’ and ‘revised frequently’. Several respondents suggested intensive CKD-oriented training while onboarding new medical officers, and continuing medical education activities in the form of renal simulcasts and practical case-based discussions by nephrologists.
Furthermore, all participants expressed an immediate need to improve patient awareness, knowledge and impart self-management skills to facilitate primary care CKD management. Respondents suggested implementation of multi-pronged approaches to patient education and increasing awareness.
“I suppose your usual public education and national programs and all that but I suppose again back to either the clinic staff so it could be the nurses, it could be the doctors, it could be just pamphlets that we give them to read and so on. I think awareness in many forms, I think it is a multi-form approach, you cannot rely on one particular path to improve awareness for CKD.” Participant 08_Physician.
Professional role and identity & beliefs about consequences
With a strong sense of professional identity as the ‘key caregiver’ for patients many primary care physicians strongly believed they could manage early-stage CKD. However, they sought more clarity on their role in the CKD care pathway and ‘categorizing patients who need to be cared for at primary care from the SOC’. However, nephrologists expressed the need for mutual discussions to set agreeable guidelines for shared care of patients with more advanced CKD. Importantly, nephrologists viewed the role of family physician clinic managed by physicians trained in family medicine enabling better rapport and facilitating continuity of care for CKD.
Belief about capabilities & optimism
Many physicians were comfortable, optimistic, and confident managing early CKD in primary care. But their self-rated confidence was variable with senior physicians perceiving greater confidence compared to junior physicians. A nephrologists concurred that physicians were confident and capable of achieving clinical treatment goals to mitigate CKD risks.
“To be fair they (primary care providers) are pretty good at handling all these diabetic control and things like that, they are in fact quite apt at doing all these things, adjustment things. You just need to give them that that confidence, that they currently they are going on the right track, that they will go and do it properly” Participant 18_Nephrologist.
Few participants stressed the need to cultivate ‘activated and informed patients’ to improve their self-efficacy for chronic disease management. Motivational techniques were regarded as useful, to help delve deeper and understand root cause for non-adherence and conveying messages across in a manner to reassure and reduce patients’ anxiety associated with CKD diagnosis. In all, patient activation and motivational counseling were viewed as patient-oriented facilitators.
Intentions and goals
Intention and goals of CKD management were apparent with HCPs unequivocally focusing on risk factor management by controlling diabetes, hypertension, and proteinuria and managing CKD progression. A vast majority of participants advised on smoking cessation, counselled patients on avoidance of non-steroidal anti-inflammatory drugs (NSAIDs), and consciously reviewed medications to adjust to safe renal doses to prevent deterioration in kidney function.
Memory attention and decision process
Respondents acknowledged the need for supporting decision-making for nephrology referrals. The physicians preferred more stringent pre-defined criteria for referrals, ensuring early nephrologist review, aiming for appointments within 1 to 2 weeks. Notably, respondents suggested adopting risk-based referral to expedite appointments for at-risk patients and right-site low-risk patients to the polyclinics. Nephrologists supported using the kidney failure risk equation (KFRE) in primary care as a key medical decision-making tool to guide appropriate specialist referrals.
“Perhaps you know we should start maybe in the polyclinic as well, may be to give them a guided kind of decision-making as to that this is the right time or this patient is like this remain like this for next ten years or next two years, so don’t refer so early” Participant 20_Nephrologist.
Environmental context and resources
Most participants discussed the utility of technological dashboards to trend creatinine levels and incorporation of automated eGFR into the electronic medical record (EMR) extremely valuable for CKD management. Respondents desired reminders to order kidney tests and alerts for rising creatinine levels to support CKD management. Overall, utilizing technological infrastructure, and clinical-decision support tools enabled appropriate identification, staging, and tracking progression in CKD.
“What has been helpful in recent times was the feature where we could draw for them the creatinine levels from the electronic medical record (EMR) system, so that was really a very good feature. I’ll just put it in and it (EMR system) calculates the eGFR, and even tells you the stage of the disease, so it was an excellent feature”. Participant 10_Physician.
Nevertheless, most physicians did not favor automated referrals based on a single measure of eGFR as they believed clinical correlation was necessary prior to referral. Nephrologists concurred that although patients might fit into the referral criteria based on low eGFR, a physician input was important to assess the patient more holistically prior to referrals.
Considering the time constraints and communication barriers at primary consultation, participants recognized the need for organizational and practice changes, and adoption of team-based care. Many participants underscored the importance of having nurses and dieticians in the team to support counseling in view of the short time available at consults. Many participants suggested engaging multidisciplinary teams comprising nurses, pharmacists, and dieticians in care of patients with poorly controlled chronic disease. Moreover, physicians and nurses perceived the need for personalized motivational counselling, self-management support in terms of dietary advice and reconciliation of medications for complex multi-morbid patients. Thus, team-based care viewed important in CKD management.
“Team-based care is quite important for the patient with poorly-controlled disease, for them to know about their disease process (progression).” Participant 12_Nurse.
In addition, many respondents described collaboration and co-management between primary care and specialists to improve care coordination for CKD. Suggestions include shared-care programs with common platforms where patients visit the specialists annually and primary care every three months, akin to the congestive cardiac failure (CCF) shared-care model.
Reinforcement & behavioral regulation
Physicians emphasized the desire for ‘guidelines’, ‘handy reference’ in the form of protocols with clear framework and structured CKD care pathways to reinforce clinician behavior to enable optimal CKD management. They also complemented the new publicly funded initiatives for detection of CKD like the Holistic Approach in Lowering and Tracking Chronic Kidney Disease (HALT-CKD) for timely detection and tracking of CKD.
“This program, called the HALT CKD program, starts with the polyclinic referrals, we make them meet a certain set of criteria like when you refer you know, and you have this patient can you please make sure that they are on an ACE-inhibitor on this particular medicine, can you please make sure blood pressure has reached the target you know.” Participant 20_Nephrologist.
HCPs in primary care are the first point of contact for most patients with CKD, well-positioned to institute therapy to prevent ESKD and other complications and arrange timely referrals to nephrologists. Our study explored barriers and facilitators to CKD management in primary care, taking into account the perspectives of HCPs, including physicians (predominantly primary care physicians and nephrologists), nurses, and pharmacists involved in the continuum of care for CKD. Our findings demonstrate that HCPs believe that CKD remains neglected in primary care due to inadequacy in resource allocation, diagnosis disclosure, consultation time, physician–patient communication, lack of patients' awareness and self-management skills, and the referral clarity to nephrologists. Nevertheless, essential enablers to CKD management include CKD specific-training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and transparent criteria for nephrology referrals. Of note, physicians expressed willingness to manage early-stage CKD in the primary care setting, leveraging on a collaborative CKD care model with the nephrologists. Thus, our findings provide valuable insights for improving CKD care delivery in Singapore's primary care setting, which may also be relevant to other countries.
Our findings of barriers of knowledge and practice gaps among physicians, competing priorities with less attention to CKD in primary care, and ineffective physician–patient communication of CKD diagnosis are aligned with findings from previous studies [18,19,20]. A strong need for continuous professional education in CKD management was highlighted as key developmental area. Of note, mentorship programs with nephrologists, like those in Canada  could offer benefit. Alongside, it is vital to address barriers of patient-physician communication. Understanding key competencies and creating a competency-based curriculum to equip clinicians with skills for communication and patient engagement around CKD diagnosis  are essential to facilitate CKD management.
HCPs highlighted short consultation time, suboptimal care coordination and fragmentation of care as major barriers to CKD management which have been reported previously from several regions globally [23,24,25]. In the background of such health system and contextual barriers, HCPs desired team-based care for CKD concurrent with earlier studies [10, 20, 26]. Primary care team-based models may potentially address barriers like time and workload, patient-physician communication, and elevate CKD literacy and self-care skills for patients. Team-based model has shown to be effective in the management of chronic diseases such as hypertension, diabetes mellitus, and depression [27,28,29]. Similar collaborative team-based care models with physicians, nurses and dieticians working synergistically has enhanced both guideline-based CKD care delivery  and associated patient-provider communication.
Clear and concise guidelines with roadmap for care and referral pathways have been previously identified as enablers of CKD management in primary care [10, 31]. Although quality resources and tools exist, guidance on referral criteria is not adhered to stringently due to lack of awareness, comprehension, and challenges in uptake and utilization jeopardizing timely nephology referrals. Of note, although not currently implemented, HCPs supported the use of KFRE in practice to facilitate referral to the nephrologists. Literature has revealed that timely outpatient nephrology referral slows disease progression, reduces hospital admissions, reduces total treatment costs, and improves survival in patients with CKD . Prioritizing referrals based on instrument such as KFRE, which has been validated in local primary care clinics  are considered valuable for risk assessment and decision-making. Establishing wait-time benchmarks and risk-based triage in Canada have reduced referral delay, improved access and provided targeted care for patients with highest risk of progression to ESKD [34,35,36]. Additionally, clinical decision-support tools embedded in a common EMR could facilitate primary care-specialist communication, case review and shared decision-making in siting patients with CKD across the primary-tertiary care interface [37, 38].
In addition, patient-level lack of knowledge, awareness, and poor self-management skills perceived by the HCPs are commonly reported in literature and by us [10, 25, 39]. Lack of awareness and knowledge on their chronic condition often limits individuals to engage in desired self-management behaviours as recommended by physicians. Multipronged approach to patient education, and increasing patient engagement have been recommended as useful strategies for improving self-management of CKD .
There are clear challenges to CKD management that are persistent in primary care. Optimal CKD intervention strategies should aim to address the multiple impediments and leverage on the opportunities. Structured CKD programs with multicomponent interventions need evaluation in Singapore and similar countries.
Strengths and limitations
The study is likely among the first qualitative studies to explore HCPs’ perceptions on the barriers and facilitators to CKD management in a developed primary care community. Including different cadres of healthcare professionals in primary care and combining nephrologists' viewpoints contributed to a fuller understanding of CKD management in the care continuum. The participants had no personal or professional relationship with the interviewers, and this allowed them to express their opinions openly. We used a sound conceptual TDF framework,  to delve deep and understand the complex and interlinked barriers and facilitators in CKD management from different stakeholders’ perspective. Our findings are relevant to other primary HCPs with similar healthcare system.
Our study has its limitations. We did not include private general practitioner clinics. However, the majority of patients with chronic disease including CKD, regardless of their socioeconomic backgrounds are treated at public primary care establishments in Singapore. Furthermore, participant responses might have been influenced by the TDF-based questions, and the study was not designed for in-depth assessment of adequacy of physician knowledge and skills regarding management CKD, although questions in the topic guide covered broad principles of CKD management as per international clinical practice guidelines. Despite efforts to recruit a balanced sample, more female participants which might introduce bias.
CKD is a rising healthcare challenge in Singapore and globally. Primary care system provides the greatest opportunity to intervene and achieve better clinical outcomes in CKD. We identified potentially modifiable barriers and facilitators to optimize management of CKD in primary care from HCP’s perspectives. Foremost, CKD deserves greater priority from HCPs and health planners in primary care. Besides, gaps in care coordination, patient-physician communication and provider knowledge need urgent attention. Moving forward, collaborative team-based care models using multifaceted strategies for structured CKD management, risk stratification to prioritize nephrology referrals using validated instrument, coupled with CKD training for all primary care physicians and self-management education for patients need implementation and evaluation. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Chronic kidney disease
Estimated glomerular filtration rate
Electronic medical records
End stage kidney disease
Kidney failure risk equation
- RAS blockers:
Renin angiotensin system blockers
Specialist outpatient clinics
Theoretical domains framework
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The authors would like to acknowledge all participants, and thank nephrologists from department of renal medicine, Singapore General Hospital for their participation.
The research was supported by funding from SingHealth Duke-NUS Health Services Research Institute (HSRI). THJ is supported by the National Medical Research Council, Singapore (Senior Clinician Scientist Award) and CR is senior research associate on the study. The funding bodies had no role in the study design, data collection, analysis, and interpretation of data and manuscript writing.
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Ramakrishnan, C., Tan, N.C., Yoon, S. et al. Healthcare professionals’ perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics. BMC Health Serv Res 22, 560 (2022). https://doi.org/10.1186/s12913-022-07949-9