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Table 3 Summary of themes and illustrative quotes for facilitators to CKD management in primary care

From: Healthcare professionals’ perspectives on facilitators of and barriers to CKD management in primary care: a qualitative study in Singapore clinics

TDF Domains Themes -Facilitators Illustrative quotes
Knowledge & Skills Competent procedural knowledge & skills for diagnosing CKD “Let’s say I meet the new patient who has some risk factors and then I will order a renal panel at that point of time. Depending on the results of the renal panel if there is a decrease in eGFR, then I could basically, check for any previous readings of eGFR. If it is more than 3 months apart according to the KDIGO is already considered CKD, then if the eGFR is normal, somehow the patients have some structural or other functional abnormalities like protein urea can also qualify for CKD.” Participant 06_Physician
“So, you do it based on the blood test, so, (things like) renal panel, eGFR (estimated Glomerular Filtration Rate) and whether they have any other co-existing disease that can lead to CKD. I think I will more rely on the SCM- Lab test results, where I can actually see the results and decide on myself whether or not it is la. For every patient I really look through the panel test anyway and even for patients they are not here for panels, I will still at the previous panel for any chronic patient, I mean we are talking about the chronic care la.” Participant 02_Physician
CKD education and training for new medical officers “I mean when I was a junior doctor, I was not very good at CKD because it was not very well taught. So that’s why I was thinking like if there were more teaching sessions and case examples to show the use of certain facilities.” Participant 09_Physician
“Including some time for some renal teaching during the induction, so that before the MO (Medical Officers) comes in, they know a bit of information”. Participant 14__Physician
“But I think may be CKD, needs to be properly taught to the health professionals and probably need to be revised quite frequently” Participant 04_Physician
Awareness, education and improving self-management skills for patients Actually, education. Health education for our patient(s) disease, like more pertaining to kidney disease, what (they) should do, what to take and then, how to prevent hypertension (and) all these (diseases). Educating patient (is) also important.” Participant 12_Nurse
The first thing is the awareness. The first thing is awareness, like, we should educate more of the patients (on) what they have (for their) underlying condition, and what they should do to keep health in the first place.” Participant 15_Physician
Professional role and identity & Beliefs about consequences Improving clarity on the role of primary care physician in CKD care pathway May be more communication between the specialist and the primary care, so that we can clearly define the stage of CKD, that can comfortably managed in the polyclinic setting and those patients who need to be cared for at the SOCs” Participant 05_Physician
Maybe also clarity of roles, because at this point, I’m not sure when the kidney doctors wants to see the cases because the climate has changed (and) there’s probably quite A LOT OF CKD patients around. So, they may be swamped with CKD (Stage) 3 and perhaps then, how do we manage some of the CKD (patients)—which I think we CAN” Participant 10_Physician
Family physician clinic-enabling rapport and continuity of care “I do have a few but mainly at the family physician clinic (FPC) but FPC is a slightly different clinic as you see more complex patients’ longer consults, those you see them back quite frequently so that one in terms of continuity of care is not an issue, usually there will be some correspondence with the specialist and send back to you, that one not a problem.” Participant 09_Physician
“When I run the family clinic they (patients) have seen me for about 5 to 10 years. So they are quite accepting to it but in general clinic I do have hurdles sometimes because they may or may not agree. In this case we tell them, “Ok you think about it, next visit we will do it”. Participant 08_Physician
I mean I love that chronic system, but I am not sure of what the name of that system is or program where they usually see one doctor, and then because, I can tell right with the notes, I look at the prescription it is always the same polyclinic doctor who is prescribing and then that kind of system I feel that patient is actually is more aware of his condition, there is a lot more better communication, usually the patient groups who actually know, when I talk to them I feel that they understand a bit more. And the polyclinic system has done very well for those patients. And as I mentioned just now it makes it easier if I do want someone or somebody to communicate with because I know who to look for.” Participant 19_Nephrologist
Beliefs about capabilities & Optimism Confident managing CKD in primary care “So, of course, ours is (that we are) confident about blood targets, because you code the proteinuria, you look for proteinuria to see how’s the situation, monitor through the trends, and you are looking specifically at medications like ACEs (angiotensin-converting-enzyme inhibitor), ARBs (Angiotensin II receptor blockers), ensure they are on board, (that) they are maximized to whatever the patient can tolerate; (and) LDL glycaemic target(s), so I think that these are very fundamental, and I think primary care is actually quite confident in doing that.” Participant 10_Physician
“I think it (confidence) is sufficient. I think the education we get and the guidelines we get from our management, generally enough for us to manage them (patients with CKD) comfortably.” Participant 08_Physician
Patient activation through motivational interviewing “So in order to motivate patients, I think like I mentioned before, you know about motivation interview right? It is how you put the message across the patients, how do you want to educate your patients, you must do this, you must do that, that patients will not follow. You must tell them, “Sir you only see me three monthly four monthly, the optimal of your health is in your hands, you really have to take care of yourself. You must be responsible and you don’t want it (disease) to be getting worse and worse, stroke coming in, heart attack coming in kidney failure coming in. So I think it is good to find out from patients their main issue, the root cause of non-compliance. It is how you put the message across the patients, how do you want to educate your patient” Participant 16_Nurse
Yes, the group still willing to take medications or to protect their body, when you just highlight to them what is the purpose of the medications they will take it. But, the group not interested in their health, you need to follow other techniques to motivate them and what is the value actually. Basically, you need activated you need an informed patient and you also need an activated team. You cannot have none of each or one of two. If both activated, then you can actually have a better management of the chronic disease” Participant 06_Physician
Intentions & Goal Deliberate risk factor management to delay CKD progression “I would just manage the patient based on making sure that they don’t progress to Stage 4 or Stage 5, by managing their chronic disease, like OTHER chronic disease like Diabetes, Hypertension, (to) the best (ability) I can. Then, (I) explain to the patient, you know, that other causes that can make kidney functions go worse” Participant 01_Physician
“I think as a family physician just to recognize those who are at risk of developing CKD and also prevent them to get that. Secondly, if they do have CKD prevent them from worsening control of chronic diseases.” Participant 04_Physician
Memory attention and decision process Facilitating decision making for nephrologist referral – Fast track referral and KFRE You need to in-build this into the whole system because now you know the internet is all cut off you can calculate it by yourself on your laptop and on your hand phone, but how difficult and how challenging that is, if you can ultimately produce that number and then it’ll be easier thing for them to refer to. KFRE I think is a good way to go, and that’s what I was thinking for my discharge criteria also. If patients they can be safely discharged and they are low risk of progression. So yes, KFRE is a good way.” Participant 18_Nephrologist
“I think using stricter guidelines, so those who need it, will get it first. So if you could have, for this patient may be a fast track queue or normal queue, but they need to do the blood test and it is a quick one and non-fasting we try to keep it in the afternoon, so they don’t queue in the morning fasting bloods, but sometimes that is also difficult but fast track will make a difference, then they should be more willing to do this.” Participant 08_Physician
“Fast track referrals are for patients’ that (aa) polyclinic deems as need to be seen soon. So, fast track I don’t think we have any issue with fast tracking them. So they have fairly early appointments, so the fast track ones are seen quite quickly or you know it’s not going to be like a few months wait, definitely within 1–2 weeks most of the time.” Participant 19_Nephrologist
Environmental context and resources Utilizing clinical decision support tools for CKD care “So, it is good that we have a built in calculator now that tells us what stage of CKD the patient is at, that helps to facilitate the identification of the patient. Secondly, I think it is good that now the SCM system actually sort of provide us with the criteria when we are supposed to refer. So that is another good point, I think those are the facilitators.” Participant 05_Physician
“Recently Dr XXXXX in SHP also started this calculator thing so it can also be used and he also built in KDIGO score into this calculator. I think it is quite good, the one most convenient one is the Clin doc one because once you click the thing it (eGFR) will be auto calculated. So I felt it’s very useful.” Participant 06_Physician
Multidisciplinary team-based delivery of care “Team-based care. Like, we have team-based care whereby the MDT (Multidisciplinary Team) cases will see the nurse counsellors first before they see the doctor. All these will help with the control of the patient(s), counsel the patients on their diet (and) all these. 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
So your pharmacist will be advising them on medications and side-effects and nurse will be advising them on diet and medication timings and all that. The doctor will be advising on the future on the prognosis and I think there is a place for team-based care. I guess all these things are already in place but if you want to improve by getting somebody to counsel patients with CKD and sort of follow them up from the moment they start the counselling to see whether there is change in lifestyle and so on.” Participant 08_Physician
Reinforcement & Behavioral regulation Reinforcing provider knowledge and structured CKD care pathways “So I mean if there is education on the implementation part of it would be good. I mean, the CKD part, the content generally you can read up on it, e.g., the guidelines, how to manage? What are the complications to look out for? I think in terms of what can be done in the polyclinic, they (junior doctors) may not know we can refer for BMD. They may not know we have fast track referral criteria. So I guess, may be that part may be highlighted to the junior doctors so that they can make use of the existing services.” Participant 09_Physician
“So, if you have a structured pathway built into this that might be, like we know the we need to order the panel every six months, so if you can reinforce to them that for our doctors, this is what should be done for CKD then I think people will follow and can benefit the patients.” Participant 06_Physician
“Definitely (clear guidelines) would be good. I mean, we have all these things on the board, to tell us, like, about guidelines for this, guidelines for that, so if there is ready information on CKD, (to) just look up and follow those guidelines would be easier, like a flowchart or something like that.” Participant 14_Physician
Implementation of programs for timely detection and tracking within primary care HALT-CKD is probably very useful and necessary because there is significant burden of CKD in our patients. I do have renal physician friends and I am sure they are drowning in such patients, and I am sure there are not enough dialysis centers. It is something we address but I think the CKD is caused by the chronic diseases, DM which we are attacking, and hypertension. So if you ask me, I think that’s also area that need a lot more attention because we can prevent the CKD in the first place, we don’t have to end up like trying to treat it and often it still gets worse with everything” Participant 07_Physician
This program we have a certain ministry, 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. Cannot just refer just because there’s CKD. But before you refer can you do something first right. Optimize the blood pressure control, optimize the glucose control, making sure that they are taking their medicine etc. etc.… So, that’s step 1” Participant 20_Nephrologist