title: Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care: a qualitative study.
abstract: OBJECTIVE
  Since 2006, general practitioners (GPs) in England, UK, have been incentivised to keep a register and monitor patients with chronic kidney disease (CKD) stages 3-5. Despite tensions and debate around the merit of this activity, there has been little qualitative research exploring clinician perspectives on monitoring early-stage CKD in primary care. This study aimed to examine and understand a range of different healthcare professional views and experiences of identification and monitoring in primary care of early-stage CKD, in particular stage 3.
  
  
  METHODS
  Qualitative design using semistructured interviews.
  
  
  METHODS
  National Health Service (NHS) settings across primary and secondary care in South West England, UK.
  
  
  METHODS
  25 clinicians: 16 GPs, 3 practice nurses, 4 renal consultants and 2 public health physicians.
  
  
  RESULTS
  We identified two related overarching themes of dissonance and consonance in clinician perspectives on early-stage CKD monitoring in primary care. Clinician dissonance around clinical guidelines for CKD monitoring emanated from different interpretations of CKD and different philosophies of healthcare and moral decision-making. Clinician consonance centred on the need for greater understanding of renal decline and increasing proteinuria testing to reduce overdiagnosis and identify those patients who were at risk of progression and further morbidity and who would benefit from early intervention. Clinicians recommended adopting a holistic approach for patients with CKD representing a barometer of overall health.
  
  
  CONCLUSIONS
  The introduction of new National Institute for Health and Care Excellence (NICE) CKD guidelines in 2014, which focus the meaning and purpose of CKD monitoring by increased proteinuria testing and assessment of risk, may help to resolve some of the ethical and moral tensions clinicians expressed regarding the overmedicalisation of patients with a CKD diagnosis.
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Simmonds
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
authors.forename: Julie
authors.initials: J
authors.lastname: Evans
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK.
authors.forename: Gene
authors.initials: G
authors.lastname: Feder
authors.affiliation: National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Blakeman
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, UK NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
authors.forename: Dan
authors.initials: D
authors.lastname: Lasserson
authors.affiliation: e-Health Unit, Research Department of Primary Care and Population Health, UCL, UK.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Murray
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK.
authors.forename: Kristina
authors.initials: K
authors.lastname: Bennert
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, UK NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.
authors.forename: Louise
authors.initials: L
authors.lastname: Locock
authors.affiliation: Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) West at University Hospitals Bristol NHS Foundation Trust.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Horwood
mesh_terms: D002983:Clinical Competence; D042241:Early Diagnosis; D004739:England; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D008991:Monitoring, Physiologic; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards*; D011507:Proteinuria / Q000175:diagnosis*; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis*; D013222:State Medicine
keywords: PRIMARY CARE; QUALITATIVE RESEARCH