Institute for Evidence-Based Healthcare, Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Qld, 4226, Australia.
School of Rural Medicine, University of New England, Armidale, NSW, 2350, Australia.
BMC Prim Care. 2024 Aug 20;25(1):312. doi: 10.1186/s12875-024-02559-2.
Chronic kidney disease (CKD) is commonly managed in general practice, with established guidelines for diagnosis and management. CKD is more prevalent in the older population, and is associated with lifestyle diseases as well as social deprivation. Older patients also commonly experience multimorbidity. Current CKD guidelines do not take age into account, with the same diagnostic and management recommendations for patients regardless of their age. We sought to investigate general practitioners' (GPs') approach to older patients with CKD, and whether their assessment and management differed from guideline recommendations. We explored the reasons for variation from guideline recommendations.
This was a mixed methods study of Australian GPs. An online anonymous survey about the use of CKD guidelines, and assessment and management of CKD was sent to 9500 GPs. Four hundred and sixty-nine (5%) of GPs responded, and the survey was completed by 399 GPs. Subsequently, 27 GPs were interviewed in detail about their diagnostic and management approach to older patients with declining kidney function.
In the survey, 48% of GPs who responded found the CKD guidelines useful for diagnosis and management. Four themes arose from our interviews: age-related decline in kidney function; whole person care; patient-centred care; and process of care that highlighted the importance of continuity of care. GPs recognised that older patients have an inherently high risk of lower kidney function. The GPs reported management of that higher risk focused on managing the whole person (not just a single disease focus) and being patient-centred. Patient-centred care expressed the importance of quality of life, shared decision making and being symptom focused. There was also a recognition that there is a difference between a sudden decline in kidney function and a stable but low kidney function and GPs would manage these situations differently.
GPs apply guidelines in the management of CKD in older patients using a patient-centred and whole person approach to care. Older patients have a high prevalence of multimorbidity, which GPs carefully considered when applying existing CKD-specific guidelines. Future iterations of CKD Guidelines need to give due consideration to multimorbidity in older patients that can adversely impact on kidney function in addition to the expected age-related functional decline.
慢性肾脏病（CKD）在一般实践中得到广泛管理，并有明确的诊断和管理指南。CKD 在老年人群中更为普遍，与生活方式疾病以及社会剥夺有关。老年患者也常常患有多种疾病。目前的 CKD 指南没有考虑年龄因素，对所有患者（无论年龄大小）都采用相同的诊断和管理建议。我们试图研究全科医生（GP）对患有 CKD 的老年患者的处理方法，以及他们的评估和管理方法是否与指南建议不同。我们探讨了与指南建议存在差异的原因。
这是一项针对澳大利亚全科医生的混合方法研究。我们向 9500 名全科医生发送了一份关于 CKD 指南使用情况以及 CKD 评估和管理的在线匿名调查。有 469 名（5%）全科医生做出了回应，其中 399 名完成了调查。随后，对 27 名全科医生进行了详细访谈，了解他们对肾功能下降的老年患者进行诊断和管理的方法。
在调查中，48%的回应全科医生认为 CKD 指南对诊断和管理有用。我们的访谈中出现了四个主题：与年龄相关的肾功能下降；整体人护理；以患者为中心的护理；以及突出连续性护理重要性的护理过程。全科医生认识到老年患者固有地存在肾功能下降的高风险。这些全科医生报告说，对更高风险的管理侧重于对整个人（而不仅仅是单一疾病）的管理和以患者为中心。以患者为中心的护理表达了对生活质量、共同决策和以症状为重点的重要性。此外，人们还认识到肾功能突然下降与稳定但肾功能较低之间存在差异，全科医生会以不同的方式处理这两种情况。
全科医生在管理老年患者的 CKD 时应用指南，采用以患者为中心和整体人护理的方法。老年患者的多种疾病患病率较高，全科医生在应用现有的 CKD 特定指南时会仔细考虑这些疾病。未来的 CKD 指南需要充分考虑除预期的年龄相关功能下降之外，还会对肾功能产生不利影响的老年患者的多种疾病。
