Datar Manasi, Ramakrishnan Saranya, Montgomery Elizabeth, Coca Steven G, Vassalotti Joseph A, Goss Thomas
Boston Healthcare Associates, Boston, MA, USA.
National Kidney Foundation, Inc., New York, NY, USA.
BMC Public Health. 2021 May 17;21(1):930. doi: 10.1186/s12889-021-10959-7.
A majority of diabetic kidney disease (DKD) patients receive medical care in the primary care setting, making it an important opportunity to improve patient management. There is limited evidence evaluating whether primary care physicians (PCPs) are equipped to effectively manage these patients in routine clinical practice. The present study was undertaken to identify gaps in primary care and unmet needs in the diagnosis and monitoring of DKD in type 2 diabetes (T2D) patients among PCPs.
This was a qualitative analysis based on 30-45-min interviews with PCPs treating T2D patients. PCPs were recruited via email and were board-certified, in practice for more than 3 years, spent most of their time in direct clinical care, and provided care for more than three T2D patients in a week. Descriptive data analysis was conducted to identify and examine themes that were generated by interviews. Two reviewers evaluated interview data to identify themes and developed consensus on the priority themes identified.
A total of 16 PCPs satisfying the inclusion criteria were recruited for qualitative interviews. Although the PCPs recognized kidney disease as an important comorbidity in T2D patients, testing for kidney disease was not consistently top of mind, with 56% reportedly performing kidney function testing in their T2D patients. PCPs most frequently reported using estimated glomerular filtration rate (eGFR) alone to monitor and stage DKD; only 25% PCPs reported testing for albuminuria. Most PCPs incorrectly believed that a majority of DKD patients are diagnosed in early stages. Also, early stages of DKD emerged as ambiguous areas of decision-making, wherein treatments prescribed greatly varied among PCPs. Lastly, early and accurate risk stratification of DKD patients emerged as the most important unmet need; which, if it could be overcome, was consistently identified by PCPs as a key to monitoring, appropriate nephrologist referrals, and intervening to improve outcomes in patients with DKD.
Our study highlights important unmet needs in T2D DKD testing, staging, and stratification in the PCP setting that limit effective patient care. Health systems and insurers in the U.S. should prioritize the review and approval of new strategies that can improve DKD staging and risk stratification.
大多数糖尿病肾病（DKD）患者在初级保健机构接受治疗，这为改善患者管理提供了重要契机。评估初级保健医生（PCP）在日常临床实践中是否有能力有效管理这些患者的证据有限。本研究旨在确定初级保健中存在的差距以及PCP对2型糖尿病（T2D）患者DKD诊断和监测方面未满足的需求。
这是一项基于对治疗T2D患者的PCP进行30 - 45分钟访谈的定性分析。通过电子邮件招募PCP，他们均获得委员会认证，从业超过3年，大部分时间用于直接临床护理，且每周为超过三名T2D患者提供治疗。进行描述性数据分析以识别和审查访谈中产生的主题。两名评审员评估访谈数据以识别主题，并就所确定的优先主题达成共识。
共招募了16名符合纳入标准的PCP进行定性访谈。尽管PCP认识到肾病是T2D患者的重要合并症，但对肾病的检测并非始终是首要考虑的事项，据报道，56%的PCP对其T2D患者进行肾功能检测。PCP最常报告仅使用估计肾小球滤过率（eGFR）来监测和分期DKD；只有25%的PCP报告检测蛋白尿。大多数PCP错误地认为大多数DKD患者在早期被诊断。此外，DKD的早期阶段成为决策的模糊领域，其中PCP开出的治疗方案差异很大。最后，DKD患者的早期准确风险分层成为最重要的未满足需求；如果能够克服这一需求，PCP一致认为这是监测、适当转诊至肾病专家以及干预以改善DKD患者预后的关键。
我们的研究突出了初级保健环境中T2D DKD检测、分期和分层方面重要的未满足需求，这些需求限制了有效的患者护理。美国的卫生系统和保险公司应优先审查和批准能够改善DKD分期和风险分层的新策略。
