In-Gu Kang, JoAnn S Oliver, Nayoung Kim, Ashley Abawi, Audrey Boahemaa Kusi, Felecia G Wood, Pamela P Foster, Sharlene D Newman
Three themes emerged. First, CKD awareness, education, and preparedness: patient awareness was uneven and often absent even under nephrology care; education was multidisciplinary and stage-sensitive but emotionally constrained. Second, dialysis decision-making: planned outpatient initiation was distinguished from unplanned emergency starts, the latter associated with reduced patient choice and worse outcomes; modality discussions typically began at an estimated glomerular filtration rate (eGFR) of approximately 20 mL/min/1.73m² but timing varied widely; nephrology clinicians sometimes omitted home dialysis options when patient support seemed uncertain; and family involvement was central to adherence and decision quality. Third, barriers, supports, and clinical management: nonadherence reflected structural barriers, financial hardship, health literacy, transportation, and delayed referral, rather than motivation, while the clinician-patient relationship was a modifiable adherence determinant limited by understaffed support services.
INTRODUCTION: The clinician-identified barriers to person-centered chronic kidney disease (CKD) care remain poorly characterized among socioeconomically disadvantaged populations. We examined nephrology clinicians' perspectives on patient preparation, dialysis decision-making, and structural barriers to inform multilevel intervention.
METHODS: A qualitative descriptive study using semi-structured interviews and thematic analysis following Braun and Clarke's (2006) approach [29] included 22 English-speaking nephrology clinicians recruited via snowball sampling. Transcripts were analyzed thematically.
RESULTS: Three themes emerged. First, CKD awareness, education, and preparedness: patient awareness was uneven and often absent even under nephrology care; education was multidisciplinary and stage-sensitive but emotionally constrained. Second, dialysis decision-making: planned outpatient initiation was distinguished from unplanned emergency starts, the latter associated with reduced patient choice and worse outcomes; modality discussions typically began at an estimated glomerular filtration rate (eGFR) of approximately 20 mL/min/1.73m² but timing varied widely; nephrology clinicians sometimes omitted home dialysis options when patient support seemed uncertain; and family involvement was central to adherence and decision quality. Third, barriers, supports, and clinical management: nonadherence reflected structural barriers, financial hardship, health literacy, transportation, and delayed referral, rather than motivation, while the clinician-patient relationship was a modifiable adherence determinant limited by understaffed support services.
DISCUSSION: Nephrology clinicians identified patient awareness, education timing, provider variability, and structural barriers as modifiable determinants of inequitable CKD outcomes. Multilevel intervention targeting pre-dialysis education, primary care coordination, reimbursement reform, and social support infrastructure is needed.