General practitioners’ perspectives on management of early-stage chronic kidney disease: a focus group study

Given the explorative character of the research aim, we considered a qualitative approach to be the most appropriate. We selected a focus group design because perspectives are more likely to be revealed by interaction and discussion with peers. Grounded theory was used as a theoretical framework [18]. We used the consolidated criteria for reporting qualitative health research (COREQ) as a reporting structure [19]. Besides adjustment of the topic list, we made no further modifications of the methods during the study.

Four focus group interviews were conducted with 27 Dutch GPs. We recruited (by phone and e-mail) from practices that had participated in the CONTACT study (Consultation Of Nephrology by Telenephrology Allows optimal Chronic kidney disease Treatment in primary care) [20]. These GPs were definitely informed about the guideline. We assumed they used the guide in daily practice, thus being able to provide knowledge about the perspectives of implementation of CKD management. In the Netherlands, GPs are responsible for providing and implementing CKD care. Although Dutch nurse practitioners (NPs) are involved in care programmes for diabetes and cardiovascular disease, their involvement in CKD care is minor. We therefore recruited only GPs. Two GPs were not involved in the CONTACT trial study. They participated because two participants in focus group 4 cancelled at the last minute. They were involved in scientific research and familiar with the guideline.

A purposive stepwise sampling strategy [21] was applied to ensure heterogeneity for gender, age, urbanization, and experience in general practice (Table 1). Sampling, data collection and analysis occurred iteratively. Practice and personal data were collected prior to the interviews. All GPs consented to participation, and they were assured that anonymity and confidentially was guaranteed. No patient data were used.

Before starting, a topic list (Additional file 1) was created by reviewing relevant literature and in consultation with the research team and two CKD-patients of the Dutch Kidney Foundation. A senior psychologist (KvS) with extensive experience in medical healthcare and chairing focus group studies moderated the focus groups. Either one of the two investigators (CD or SB), both GP trainees, PhD students and trained in qualitative research, and a research intern (BB) observed the focus groups and noted non-verbal communication and details about group interaction. The sessions lasted 120 min each. After each focus group, the investigator and Chair discussed observations made during the sessions and adjusted the topic list for each following focus group, in discussion with the research team. All focus group discussions were audio-taped and transcribed verbatim. In the analysis of the fourth focus group, no new codes or concepts were found. We decided that saturation had been reached at that moment.

The transcripts were analysed with the constant comparative analysis method [21] and with the aid of a computer program (Atlas.ti version: 7.1.5). Analyses started after the first focus group interview. The analysts (SB and BB) independently used open and inductive coding. They discussed and merged codes after each focus group. In the case of disagreement, members of the peer group (MD and WG) were consulted. A consensus code list arose, which was used to code the second transcript. New codes were added and discussed as described after each next coded transcript. After three focus group sessions, another researcher (CD) became involved as SB left the research project. This researcher coded all transcripts as a third coder. The research intern (BB) and the second researcher (CD) independently coded the fourth session. After saturation was reached, the codes were sorted into categories and themes. It took five consensus meetings in which members of the research group (CD, SB, BB, MD, NS, and WG) participated to construct the final thematic map. For a detailed description of the analysis process, see Additional file 2. A native-English speaker translated the illustrative quotes.

Four focus group interviews were conducted between November 2014 and March 2016. A total of 147 GPs were invited to participate, of whom 71 responded. Forty-one GPs were interested in participating, while 30 GPs declined, mostly due to lack of time. Altogether, 27 GPs were included by purposive sampling, and 5 to 8 GPs participated in each session. Table 1 presents the characteristics of the participants.

Five main themes emerged: 1) defining CKD, 2) knowledge and awareness, 3) patient-physician interaction, 4) organisation of CKD care, and 5) value of the guideline. For a detailed description of codes, categories and themes, see Additional file 3.

CKD was experienced as a difficult and abstract concept. CKD seems intangible. The diagnosis is not a clinical one, but is merely based upon laboratory findings without patient complaints and- in the view of participants- in some cases without clinical consequences. The participants struggled to interpret the eGFR values due to eGFR fluctuations and strict cut-off points. Age and physiology were considered relevant to interpret eGFR values, but also whether to label patients with the CKD diagnosis. Participants felt that there was no fixed definition of CKD. Furthermore, whether CKD is a disease on its own or a risk factor for cardiovascular disease, like hypertension, was discussed.

“The initial question was what is your picture of chronic kidney damage, and honestly, that picture is just a check mark in a row of risk factors.” (FG1, man, 60-70y)

Perception of CKD as an abstract concept is a key finding in this study. The perceived abstract CKD concept seems to play a role in all formulated themes. It influences the GPs’ experienced confidence on CKD knowledge. Clinical relevance also seems to be lacking, and there is scepticism concerning treatment benefits for patients. GPs act at their own discretion, taking into account patients’ age, prognosis and quality of life. The interdisciplinary guideline is therefore seen as a rough guide rather than leading. The abstractness of the CKD concept forms an obstacle in conveying the CKD concept to patients.

The heterogeneity of the participants supported the generalisability of the findings. Internal validity was established through independent coding in triplicate, the use of Atlas.ti and the mind-mapping sessions with the research team in which additional perspectives and interpretation of analysis and findings were discussed. Analysis by three analysts and similar findings from previous other studies helped to triangulate the findings. The rigor of the data is supported by the iterative approach of the focus group and the interim data analysis. Some limitations should be considered. The focus groups were performed in Dutch, so that representative quotations needed translation. This may have caused loss of nuance, which we tried to limit through translation by a native-English speaker. The moderator was a psychologist, which could be a restriction regarding in-depth interviewing in the medical field. Another possible limitation is that most recruited GPs were previous participants in the CONTACT study. This might be related to a special interest in the research theme, possibly influenced their knowledge of and commitment to the subject. However, GPs who are not familiar with the subject may have even more difficulties with CKD care while they have insufficient knowledge about the guideline to provide answers to the research question. In order to avoid analysis bias as much as possible, the research team members differed in profession, age, experience regarding CKD care, and experience as a GP. Some had been involved in previous research on CKD (including the trial), but others had no specific experience in CKD research when the focus group study was performed. All researchers were GPs (in training). These background factors may have influenced our findings, but we can’t indicate the direction of a possible bias.

Our study provides insight into the perspectives of GPs concerning early-stage CKD management and could give input for future quality-improvement interventions. A major direction should be to improve GPs’ understanding of the clinical concept of CKD. This could be done by education, which should also focus on clinical relevance, prognostic value of CKD, proteinuria and the interpretation of eGFRs in relation to age and comorbidity. Instructions on how to give a suitable explanation of the CKD diagnosis to patients might as well be part of GPs’ education.

Our opinion is that embedding CKD care in an integrated care programme of all cardiovascular risk factors, including CKD, hypertension and diabetes, may support GPs and patients to maintain an overview. For those who were not diagnosed with diabetes or cardiovascular disease, a comparable care program provides the best chance of creating awareness and improving the quality of care for CKD patients. The tension between disease-specific guidelines and the holistic care preferred by GPs is - besides the abstract concept of CKD - perhaps the most important implementation barrier. GPs wish to maintain a patient-centred approach in providing high-quality CKD care, deviating from guideline recommendations when necessary.