Table 2 Summary of themes and illustrative quotes for barriers to CKD management in primary care

Knowledge & Skills

Knowledge and practice gaps among junior doctors

“I must say that within the polyclinic setting, we have not been paying that much attention in terms of treatment of CKD, although we know the stages. I believe that knowledge gap may also play a role for lot of the physicians, because we have been actually driving more towards like management of chronic illnesses, even if you look at our doctor’s guidebook it doesn’t really talk much about the CKD management, which is from the specialist clinic.” Participant 05_Physician

“When I was a junior doctor, I was not very good at CKD because it was not very well taught.” Participant 09_Physician

Lack of awareness and self-management skills among patients

“They come in every time, frequently come in (over) little thing(s), they will come in and see us, you know. I think their health knowledge is not so good for Singaporeans. You know, even for diet (and) all these (things), they can be taking a lot of things, the rich (people) can be very unhealthy; the poor one(s) can be taking something that is not (a) balanced diet.” Participant 12_Nurse

“We are struggling with a large group of patients with all sorts of problems, like, from poor control, to perhaps symptoms of CKD, to smoking (et cetera), so it’s like (a) whole package right, from either the literacy and their difficulties in reality (et cetera) (that) they are not able to activate themselves to change behaviour, so I think that is really more of the issue rather than communicating the diagnosis.!” Participant 10_Physician

Professional role and identity & Beliefs about consequences

Competing priorities in primary care, CKD less attention by healthcare providers

I think we cannot generalize this because it depends during the consultation, if there is something that is pressing say for example high blood pressure hypertension and CKD, if that visit itself the blood pressure is high obviously that is going to my priority. But given that, if everything is stable then I think they should be given equal weightage in terms of attention. 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

“CKD is currently not viewed in the same league as say diabetes, stroke and heart attacks okay. So, barriers would be whether the providers themselves have equal like, do they view CKD as an equally important condition to treat. I think that’s quite fundamental” Participant 10_Physician

Beliefs about capabilities & Optimism

Apprehensions and discomfort in managing CKD complications

“I think the anaemia ones, anything beyond that what we can give, I think it is hard for us to manage. If let’s say, they already on the maximum iron that we can give here.” Participant 02_Physician

“Because I mean, lot of times we refer on and we forget about the other things to monitor, so I feel that prevalent problem in our practice is we don’t like monitoring of anaemia, monitoring of calcium level all these and monitoring of bicarb levels we don’t do it very frequently”. Participant 04_Physician

Intentions & Goal

Intention to convey CKD diagnosis in simple terms -ineffective disclosure

“I will just say in general because I don’t find that if they know the stage, they (patients) will really understand or appreciate it. In the more serious maybe they start having more of the latest stages I will tell them, your kidney is so much damaged now like 60% or 70 just to kind of give them an idea of how bad it is” Participant 07_Physician

“Number one, they don’t see the reason why they have been referred. Most of the time in CKD 3b even 4 they are fairly asymptomatic right, so they don’t see the reason, they don’t feel unwell. It’s not like derm (skin) we can see is itchy or they would go and see the pathologist, if it’s itchy it bothers them. CKD is asymptomatic, so a lot of times people don’t see the reason for coming as I mentioned to you. So, if it’s not well communicated to them, they don’t understand why they are here (at specialist clinic)” Participant 19_Nephrologist

Lack of communication- patients don’t see the reason to visit specialists

“So [patients] don’t really see the point of seeing renal, because sometimes when they see renal. Renal might just order a bunch of blood for them and they don’t really understand the need for it and what’s the implication of the bloods and don’t really see anything been done for them.” Participant 02_Physician

“They are aware sometimes; they say they have a little bit of protein in urine, sometimes a little bit of blood. But that’s nothing, nobody tells me (the patient) that it’s dangerous, doesn’t mean that I have a kidney disease. They (patients) don’t know what kidney disease is…. Then they (patient) come to see us, we tell them your kidney is 50% gone (failed) you know, they say hah!! That’s the thing, so, this is a group of people, so we do feel sometimes very frustrated for those patients who don’t know why they are coming for, and on the ground the polyclinic GP don’t explain to them before they come. Participant 20_Nephrologist

Memory attention and decision process

Limitations in decision making for nephrology referrals

“It’s not so easy also, even though we have some doubts regarding that, is there something we can hence do for the patient, or whether he needs some kind of specialist opinion (and therefore) referring is the best thing.” Participant 15_Physician

“With nephrotic-range proteinuria, yes, we would (refer), or basically just an increasing trend of creatinine or a reducing trend of eGFR at a slightly fast rate—I don’t really have a figure, it’s just like a feel when I look at the numbers—so those (cases) will be the conscious decision whether a renal physician (should) already be on-board. So, and that would be where we do well and, I think, where we don’t do so well.” Participant 10_Physician

Environmental context and resources

Short consultation time and load

“Of course, time can be one of the restrictions definitely, because you have to see a lot of patients here, and you hardly give more than five or ten minutes to each patient. And [you are] diagnosing CKD in patients who have never had any problem in their life, this can be challenging at that time because of the time restriction. But still, like if you see high creatinine levels, something is abnormal, you can still ask the patient to repeat it again, or if really, we are not sure, we you refer to the hospital. But of course, time is one of the factors here.” Participant 15_Physician

“I think time, consult time is always a big thing and you need time to explain and do things.” Participant 08_Physician

Suboptimal care co-ordination and pathways

Long waiting time for specialist appointment

“I guess in the past it used to be the long waiting time, like in the past it was more than six months, in fact even once it was like a year or something. But I think recently it is bit better and I think what would be beneficial” Participant 09_Physician

“Unfortunately, our referrals dates are 4 to 6 months away. So sometimes when you are already about 35 eGFR or whatever we just get the date first.” Participant 08_Physician

Fragmentation of care

“But like I said if they are seeing them only at ad hoc, you see them one day, then the other you see somebody else, then that rapport is never built, and it’s very difficult to break all these news to them you know.” Participant 18_Nephrologist

“Not always seeing the same doctor. Something that they’ve told me before. So, some of them do actually have the same doctor, and those tend to be, they seem happier. Some of them say that every time they come, they see a different doctor so they feel that the doctor may not actually know what’s happening to them.” Participant 17_Nephrologist

Obscure medical information exchange and communication between primary care and specialists

“We have a short- and long-term concerns for our own documentation, then in the specialist we can see their documentation, but the patient with CKD will have lot of other things and have lot of appointments. So, it just gets lost inside and we can’t rely on patients to always remember to bring their memo on hand, they will misplace… because sometimes you have to trouble shoot tons of tracking notes before you find the correct correspondence for the one that you referred for.” Participant 09_Physician

“So yes, it can be mixed for example you unless you put in the long-term concerns and yes then it will be (available), you would see that, otherwise you can’t miss the previous.” Participant 03_Physician

Lack of resources- dieticians, tests, medications

“I think to manage in primary care can sometimes be, difficult because we don’t have access to all of the test and may be not all the medications that patients can potentially have their choices too” Participant 03_Physician

“I mean so subsequent later stage of CKD, they need more monitoring like calcium levels or may be the bicarbonate levels which we don’t normally very routinely do here. May be not as frequent it should be done.” Participant 04_Physician

Reinforcement & Behavioral regulation

Believe primary care not doing enough for CKD

“So, in the SOC’s I am sure, for patients with CKD, they will be screening regularly for example, full blood count because anaemia is one of the complications and they also might be doing things like phosphate levels, calcium levels, they might start patients on calcium pills. So, all this, if you ask me, I think we never do any of this for our patients. Because by certain stage we would have sense it that “Ok this patient is bad enough to refer to the SOC, so from the point we diagnose someone with CKD till the point that we think that the patient is bad enough to refer SOC, we almost never do anything. Participant 05_Physician

“Every visit, we are saying the same things in primary care, so I think our frustration is that we KNOW all these things, but how come sometimes we just can’t seem to be moving on with the patient, we’re just always stuck in this circle of like, “I know all these, but I can’t do that.” So, I think that is like one of the key things that will change how we deliver care. How do we change this circle of things of just saying things happily [laughs] again and again? It’s not like nobody knows. We all know it but we just can’t seem to get anywhere. Participant 10_Physician