Tam-Tham Helen, King-Shier Kathryn M, Thomas Chandra M, Quinn Robert R, Fruetel Karen, Davison Sara N, Hemmelgarn Brenda R
Departments of Community Health Sciences and.
Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; and.
Clin J Am Soc Nephrol. 2016 Nov 7;11(11):2012-2021. doi: 10.2215/CJN.04510416. Epub 2016 Aug 22.
Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method.
Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively).
We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.
基层医疗环境中，对5期慢性肾脏病（估算肾小球滤过率<15 ml/min/1.73 m²）成人患者的保守治疗越来越普遍。我们旨在调查基层医疗医生对老年患者进行保守治疗时所感知到的障碍和促进因素。
设计、地点、参与者与测量方法：2015年，我们对加拿大艾伯塔省所有基层医疗医生进行了一项基于人群的横断面调查。符合条件的参与者需有照顾年龄≥75岁、5期慢性肾脏病且不打算开始透析的成人患者的经验。问卷项目基于行为改变轮指导下的定性描述性研究，并进行了表面效度和内容效度测试。根据改良的迪尔曼方法，通过邮政信件和/或传真联系医生。
409名符合条件的基层医疗医生完成了问卷（回复率9.6%）。大多数受访者为男性（61.6%），年龄在40 - 60岁之间（62.6%），在大/中型人口中心执业（68.0%）。在基层医疗环境中提供保守治疗最常见的障碍是无法获得支持以让患者维持居家状态（39.1%的受访者；95%置信区间，34.6%至43.6%）。第二常见的障碍是与肾脏专科临床专业知识有限的非医生提供者合作（32.3%；95%置信区间，28.0%至36.7%）。基层医疗医生表示，增强其提供保守治疗能力的两个最常见策略是能够通过电话联系肾病专家或保守治疗诊所的临床工作人员（分别为86.9%；95%置信区间，83.7%至90.0%和85.6%；95%置信区间，82.4%至88.9%）。
我们确定了重要领域，可为临床项目提供参考，以减少障碍并增强促进因素，从而改善基层医疗医生对肾脏疾病的保守治疗。特别是，基层医疗医生需要更多资源来维持患者居家状态，并通过电话联系肾病专家和保守治疗专家。
