Approximately 12.5% of all Canadians live with chronic kidney disease [1], which is characterized by a sustained reduction in kidney function and may include significant levels of protein in the urine. Early detection of chronic kidney disease allows healthcare providers to initiate appropriate management to help prevent or slow the patient’s progression to kidney failure. Most patients with early stage chronic kidney disease are managed in the primary care setting and are only referred to nephrologists if they have advanced disease or are at increased risk of progression.
International guidelines published in 2013 from Kidney Disease Improving Global Outcomes (KDIGO) recommend that chronic kidney disease should be classified based on estimated glomerular filtration rate (eGFR) and level of albuminuria [2]. These guidelines recommend that patients with an initial eGFR < 60 mL/min/1.73 m2 should have a repeat serum creatinine test within three months to diagnose chronic kidney disease [2]. Although these guidelines are well recognized by nephrologists, primary care providers are generally not aware of them. Additional efforts have been made in several jurisdictions to bridge this gap in primary care. For example, the Ontario Renal Network (ORN), the provincial agency responsible for the delivery of kidney care services in Ontario, Canada, released a flow diagram based on these clinical guidelines to aid primary care providers with appropriate screening, monitoring, management, and referral for chronic kidney disease (the KidneyWise toolkit) [3]. This toolkit provides specific advice for ordering follow-up serum creatinine tests. The ORN has attempted wide dissemination of this toolkit through national primary care conferences, social media, and integration into electronic medical records (EMRs).
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Based on a previous population-based study among Ontario primary care providers, only 49% of patients with initial abnormal eGFR values received a repeat serum creatinine test in the following six months [4]. These findings are consistent with another Ontario study among primary care providers using an EMR [5]. Similarly, studies in other countries have shown that only 14 to 28% of patients with an initial eGFR < 60 mL/min/1.73 m2 have a documented diagnosis for chronic kidney disease [6,7,8,9]. It is not clear why this guideline recommendation is not being followed in practice for half of the patients.
Previous literature on evidence-practice gaps in primary care have demonstrated that guideline-based recommendations are generally not being followed in practice due to lack of time and resources, limited relevance of research to practice, and patient-related factors [10,11,12,13,14,15,16]. Based on our detailed literature review, we did not find any previous studies on primary care providers’ perspectives on the enablers and barriers to completing follow-up serum creatinine tests to confirm chronic kidney disease (Additional file 1). It is not clear if previously identified evidence-practice gaps are relevant to this practice.
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There are many different frameworks and theories on clinical practice change and implementation of guidelines [17,18,19]. We used a robust framework of behavioural change, referred to as the Theoretical Domains Framework (TDF), in our study to shape our research questions, interview guide, and analysis [17, 20]. The TDF was developed to help understand why evidence-based guidelines may not be followed in practice and to help develop strategies to improve implementation of evidence into practice. It is a consensus framework based on 33 behaviour change theories and 128 theoretical constructs to inform implementation research [17]. Based on a validation study of the original TDF, the refined framework includes 14 domains and 84 theoretical constructs [20].
The purpose of this qualitative descriptive study was to use the TDF as a framework to elicit and describe the perceived enablers and barriers to following recommendations for ordering a repeat serum creatinine test after an initial abnormal kidney function test result by Ontario primary care providers.
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