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Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care: a qualitative study
  1. Rosemary Simmonds1,
  2. Julie Evans2,
  3. Gene Feder1,
  4. Tom Blakeman3,
  5. Dan Lasserson2,4,
  6. Elizabeth Murray5,
  7. Kristina Bennert1,
  8. Louise Locock2,4,
  9. Jeremy Horwood1,6
  1. 1Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK
  2. 2Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
  3. 3National 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
  4. 4NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
  5. 5e-Health Unit, Research Department of Primary Care and Population Health, UCL, UK
  6. 6National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) West at University Hospitals Bristol NHS Foundation Trust
  1. Correspondence to Dr Jeremy Horwood; j.horwood{at}


Objectives 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.

Design Qualitative design using semistructured interviews.

Setting National Health Service (NHS) settings across primary and secondary care in South West England, UK.

Participants 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.


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