title: Specialist and primary care physicians' views on barriers to adequate preparation of patients for renal replacement therapy: a qualitative study.
abstract: BACKGROUND
  Early preparation for renal replacement therapy (RRT) is recommended for patients with advanced chronic kidney disease (CKD), yet many patients initiate RRT urgently and/or are inadequately prepared.
  
  
  METHODS
  We conducted audio-recorded, qualitative, directed telephone interviews of nephrology health care providers (n = 10, nephrologists, physician assistants, and nurses) and primary care physicians (PCPs, n = 4) to identify modifiable challenges to optimal RRT preparation to inform future interventions. We recruited providers from public safety-net hospital-based and community-based nephrology and primary care practices. We asked providers open-ended questions to assess their perceived challenges and their views on the role of PCPs and nephrologist-PCP collaboration in patients' RRT preparation. Two independent and trained abstractors coded transcribed audio-recorded interviews and identified major themes.
  
  
  RESULTS
  Nephrology providers identified several factors contributing to patients' suboptimal RRT preparation, including health system resources (e.g., limited time for preparation, referral process delays, and poorly integrated nephrology and primary care), provider skills (e.g., their difficulty explaining CKD to patients), and patient attitudes and cultural differences (e.g., their poor understanding and acceptance of their CKD and its treatment options, their low perceived urgency for RRT preparation; their negative perceptions about RRT, lack of trust, or language differences). PCPs desired more involvement in preparation to ensure RRT transitions could be as "smooth as possible", including providing patients with emotional support, helping patients weigh RRT options, and affirming nephrologist recommendations. Both nephrology providers and PCPs desired improved collaboration, including better information exchange and delineation of roles during the RRT preparation process.
  
  
  CONCLUSIONS
  Nephrology and primary care providers identified health system resources, provider skills, and patient attitudes and cultural differences as challenges to patients' optimal RRT preparation. Interventions to improve these factors may improve patients' preparation and initiation of optimal RRTs.
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, MD, USA. rfcharle@jhmi.edu.
authors.forename: Raquel C
authors.initials: RC
authors.lastname: Greer
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, MD, USA. jamelin1@jhmi.edu.
authors.forename: Jessica M
authors.initials: JM
authors.lastname: Ameling
authors.affiliation: Vanderbilt University School of Medicine, Nashville, TN, USA. kerri.cavanaugh@Vanderbilt.Edu.
authors.forename: Kerri L
authors.initials: KL
authors.lastname: Cavanaugh
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, MD, USA. bjaar@aol.com.|Nephrology Center of Maryland, Baltimore, MD, USA. bjaar@aol.com.
authors.forename: Bernard G
authors.initials: BG
authors.lastname: Jaar
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco, CA, USA. grubbsv@medsfgh.ucsf.edu.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Grubbs
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, MD, USA. carrie.e.andrews@gmail.com.
authors.forename: Carrie E
authors.initials: CE
authors.lastname: Andrews
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, MD, USA. pephraim@jhu.edu.
authors.forename: Patti
authors.initials: P
authors.lastname: Ephraim
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco, CA, USA. NPowe@medsfgh.ucsf.edu.
authors.forename: Neil R
authors.initials: NR
authors.lastname: Powe
authors.affiliation: Vanderbilt University School of Medicine, Nashville, TN, USA. julia.b.lewis@Vanderbilt.Edu.
authors.forename: Julia
authors.initials: J
authors.lastname: Lewis
authors.affiliation: Vanderbilt University School of Medicine, Nashville, TN, USA. ebele.m.umeukeje@Vanderbilt.Edu.
authors.forename: Ebele
authors.initials: E
authors.lastname: Umeukeje
authors.affiliation: Johns Hopkins Medical Institutions, Baltimore, MD, USA. lgimene1@jhmi.edu.|Nephrology Center of Maryland, Baltimore, MD, USA. lgimene1@jhmi.edu.
authors.forename: Luis
authors.initials: L
authors.lastname: Gimenez
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco, CA, USA. JamesS@medsfgh.ucsf.edu.
authors.forename: Sam
authors.initials: S
authors.lastname: James
authors.affiliation: Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA. ebony.boulware@duke.edu.
authors.forename: L Ebony
authors.initials: LE
authors.lastname: Boulware
mesh_terms: D001291:Attitude of Health Personnel; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D033183:Interdisciplinary Communication; D007407:Interviews as Topic; D008297:Male; D009398:Nephrology / Q000639:trends*; D010817:Physician-Patient Relations; D058007:Physicians, Primary Care / Q000639:trends*; D036301:Qualitative Research; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000628:therapy; D017582:Renal Replacement Therapy / Q000592:standards* / Q000639:trends; D018570:Risk Assessment; D016896:Treatment Outcome