How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis

Chronic kidney disease (CKD) is associated with increased cardiovascular mortality and morbidity as well as progression to established renal failure. Interventions in primary care, particularly the lowering of blood pressure in individuals with CKD and proteinuria and diabetes, can slow disease progression. This evidence base is codified in national guidance and in a simplified form in pay-for-performance targets. Prior to conducting the QICKD study - a cluster of quality-improvement interventions with reduction of blood pressure as its primary outcome measure - a diagnostic analysis was conducted to assess the relevance of the intended interventions.

To understand practitioners' views of CKD and its management.

Focus groups were held in five locations across England. Experienced facilitators developed a standardised approach and analysed data using the 'framework' approach.

Practitioners varied in their views of CKD and their embracing of the guidance. Some sought to implement the full guidance, others only the pay-for-performance targets. Nearly all practitioners had reservations as to whether CKD was really a disease; problematised the diagnosis of CKD purely on an estimate of glomerular filtration rate; questioned whether CKD in older people was part of natural ageing; and had experienced difficulty in explaining the condition to patients without frightening them. Most reported both problems and scepticism concerning the blood pressure targets, and acknowledged educational gaps.

Practitioners have disparate views about CKD. The quality-improvement interventions in the QICKD study will need to incorporate a large element of education. CKD guidelines may have been introduced without sufficient educational support.