title: GPs' views on managing advanced chronic kidney disease in primary care: a qualitative study.
abstract: BACKGROUND
  Chronic kidney disease (CKD) has become a significant part of the GP's workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology.
  
  
  OBJECTIVE
  To explore GPs' views of managing patients with advanced CKD and referral to secondary care.
  
  
  METHODS
  Qualitative study with GPs in four areas of England: London, Bristol, Birmingham, and Stevenage.
  
  
  METHODS
  Semi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed.
  
  
  RESULTS
  GPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient's interests.
  
  
  CONCLUSIONS
  GPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams.
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton.
authors.forename: Sarah
authors.initials: S
authors.lastname: Tonkin-Crine
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton.
authors.forename: Miriam
authors.initials: M
authors.lastname: Santer
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton.
authors.forename: Geraldine M
authors.initials: GM
authors.lastname: Leydon
authors.affiliation: Department of Palliative Care, Policy and Rehabilitation, King's College London, London.
authors.forename: Fliss E M
authors.initials: FE
authors.lastname: Murtagh
authors.affiliation: Renal Unit, Lister Hospital, Stevenage.
authors.forename: Ken
authors.initials: K
authors.lastname: Farrington
authors.affiliation: Renal Unit, Southmead Hospital, Bristol, Bristol.
authors.forename: Fergus
authors.initials: F
authors.lastname: Caskey
authors.affiliation: Department of Renal Medicine, Heart of England NHS Foundation Trust, Birmingham.
authors.forename: Hugh
authors.initials: H
authors.lastname: Rayner
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton.
authors.forename: Paul
authors.initials: P
authors.lastname: Roderick
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D019468:Disease Management; D004739:England; D005260:Female; D058006:General Practice / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010346:Patient Care Management / Q000458:organization & administration*; D011320:Primary Health Care / Q000379:methods*; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000628:therapy*; D011795:Surveys and Questionnaires
keywords: attitude of health personnel; chronic kidney disease; patient care management; primary health care; qualitative research