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Step-Wise Management of Anemia in Patients With Chronic Kidney Disease in Primary Care: Qualitative Study
Gayathri Delanerolle1, Anna Forbes1,2, Jeremy van Vlymen1
1University of Oxford, Oxford, UK.
Insights
Anemia in chronic kidney disease (CKD) is often poorly managed in primary care. An audit-based education intervention showed promise but requires modifications, particularly regarding erythropoiesis-stimulating agent (ESA) prescribing, to improve CKD anemia care.
Area of Science:
- Nephrology
- Primary Care Medicine
- Health Services Research
Background:
- Anemia is a common complication of chronic kidney disease (CKD), increasing cardiovascular risk and reducing quality of life.
- Management of anemia in CKD is frequently suboptimal, especially in primary care settings where most patients receive their care.
- There is a need for interventions to enhance the effective management of anemia in CKD patients within primary care.
Purpose of the Study:
- To qualitatively evaluate an audit-based education (ABE) intervention designed to improve CKD anemia management.
- To explore practitioner and patient-relevant outcomes, identify practice variations from National Institute for Health and Care Excellence (NICE) guidelines, and assess intervention feasibility and acceptability.
Main Methods:
- A qualitative study involving focus group discussions with practitioners (5 groups) and patients (7 individuals) from four London general practices.
- Exploration of perceptions regarding an ABE intervention for managing anemia in CKD.
- Assessment of alignment with NICE guidelines and identification of barriers and facilitators to implementation.
Main Results:
- Practitioners found the evidence-based ABE intervention's initial steps acceptable but expressed concerns about independently prescribing erythropoiesis-stimulating agents (ESAs).
- A significant gap exists between NICE guidelines and current primary care practices for CKD anemia management, including a lack of understanding of iron studies.
- Patients were often unaware of their CKD diagnosis and primarily focused on other comorbidities, though they generally trusted their general practitioners (GPs).
Conclusions:
- The initial components of the ABE intervention were well-received, but concerns regarding ESA prescribing necessitate further development.
- Shared care protocols between renal physicians and GPs could facilitate appropriate ESA use in primary care.
- Improving awareness of renal anemia and enhancing knowledge of guideline recommendations are crucial; the intervention requires modification to address these areas.
Introduction:
Anemia is common in chronic kidney disease (CKD) and is associated with increased cardiovascular risk and reduced quality of life, but is often sub-optimally managed. Most patients are managed in primary care alongside other comorbidities. Interventions to improve the management of anemia in CKD in this setting are needed.
Methods:
We conducted a qualitative study to evaluate how an audit-based education (ABE) intervention might improve the management of anemia in CKD. We explored outcomes that would be relevant to practitioners and patients, that exposed variation of practice from National Institute for Health and Care Excellence (NICE) guidelines, and whether the intervention was feasible and acceptable.
Results:
Practitioners (n = 5 groups) and patients (n = 7) from 4 London general practices participated in discussions. Practitioners welcomed the evidence-based step-wise intervention. However, prescribing erythropoiesis-stimulating agents (ESAs) was felt to be outside of their scope of practice. There was a gap between NICE guidance and clinical practice in primary care. Iron studies were not well understood and anemia management was often conservative or delayed. Patients were often unaware of having CKD, and were more concerned about their other comorbidities, but largely trusted their GPs to manage them appropriately.
Conclusions:
The first steps of the intervention were welcomed by practitioners, but they expressed concerns about independently prescribing ESAs. Renal physicians and GPs could develop shared care protocols for ESA use in primary care. There is scope to improve awareness of renal anemia, and enhance knowledge of guideline recommendations; and our intervention should be modified accordingly.
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