Oude Engberink Agnès, Marc Julie, Renk Elodie, Serayet Philippe, Bourrel Gérard, Moranne Olivier
Desbrest Institute of Epidemiology and Public Health (IDESP), INSERM, University of Montpellier, Montpellier, France.
Department of General Practice, School of Medicine, University of Montpellier, Montpellier, France.
Clin J Am Soc Nephrol. 2025 Mar 1;20(3):367-376. doi: 10.2215/CJN.0000000620. Epub 2024 Nov 21.
Pay-for-performance indicators and lack of knowledge about new drugs limit general practitioners' ability to identify target populations and perform urinary protein assays. Choosing between several possible assays is associated with confusion and exposes general practitioners to the risk of inappropriate referrals to nephrologists. Revising pay-for-performance indicators, drafting multidisciplinary guidelines, raising multiprofessional collaboration, and patient awareness should be considered.
Albuminuria testing is an easy way to identify, early on, a higher risk of cardiovascular and kidney morbidity and mortality in patients at risk. In France, the urine albumin-to-creatinine ratio is an indicator for Remuneration for Public Health Objectives (primary care pay-for-performance) for patients with diabetes or hypertension. These tests must be performed annually by General Practitioners (GPs), but are not sufficiently performed, although drug therapies depend on them. We wanted to understand the practice of urinary protein screening assays by means of a qualitative study on the experience of GPs in a French region, with a view to developing facilitating strategies.
This qualitative, semiopragmatic, phenomenological study analyzed in-depth interviews held with a purposive sample (age, sex, training, type of practice, rural/urban context) of 27 GPs, with triangulation of researchers until data saturation.
GPs recognized the assay as a systematic screening tool in accordance with the guidelines, but limited it to patients with diabetes or hypertension encouraged by primary care pay-for-performance. Noting that their intervention was limited to kidney-protective measures already in place and, unaware of the new drugs, they saw no benefits and considered it a nonpriority test. The existence of several urinary assays with varying intervention thresholds, changes in guidelines, and the fact that specialists in laboratory medicine can decide which test to use depending on reimbursement by the health insurance scheme, all contributed to GPs' confusion in prescribing and interpreting tests. One consequence of this was inappropriate referral to the nephrologist. These tests required them to adopt a patient-centered educational approach, making it difficult for certain patients to perform them.
GPs were aware of guideline recommendations to screen for albuminuria in patients with diabetes and hypertension but had difficulty interpreting the results. Their lack of perceived clinical consequences and new drugs should be targeted to improve the situation.
绩效付费指标以及对新药的了解不足限制了全科医生识别目标人群和进行尿蛋白检测的能力。在几种可能的检测方法中进行选择会导致困惑，并使全科医生面临不恰当地将患者转诊至肾病科医生的风险。应考虑修订绩效付费指标、制定多学科指南、加强多专业协作以及提高患者意识。
蛋白尿检测是一种在早期识别有风险患者心血管和肾脏发病及死亡高风险的简便方法。在法国，尿白蛋白与肌酐比值是糖尿病或高血压患者公共卫生目标薪酬（初级保健绩效付费）的一项指标。这些检测必须由全科医生（GP）每年进行，但实际执行情况并不理想，尽管药物治疗依赖于这些检测结果。我们希望通过对法国某地区全科医生经验的定性研究来了解尿蛋白筛查检测的实践情况，以便制定促进策略。
这项定性、半实用、现象学研究分析了对27名全科医生进行的目的抽样（年龄、性别、培训、执业类型、农村/城市环境）深度访谈，研究人员进行三角互证直至数据饱和。
全科医生认可该检测是符合指南的系统筛查工具，但将其局限于初级保健绩效付费鼓励检测的糖尿病或高血压患者。他们指出自己的干预仅限于已有的肾脏保护措施，且由于不了解新药，他们认为检测没有益处且并非优先检测项目。存在几种干预阈值不同的尿检测方法、指南的变化以及检验医学专家可根据医保报销方案决定使用哪种检测方法，这些都导致全科医生在开检测单和解读检测结果时感到困惑。这一情况的一个后果是不恰当地将患者转诊至肾病科医生。这些检测要求他们采用以患者为中心的教育方法，这使得某些患者难以进行检测。
全科医生知晓指南中关于对糖尿病和高血压患者进行蛋白尿筛查的建议，但在解读检测结果方面存在困难。应针对他们对临床后果和新药认识不足的问题来改善这种情况。
