Methods

1. Right-siting chronic kidney disease care – a survey of primary care physicians in Singapore • Pradeep Paul George1, Christina Ma OH2, Loh Ping Tyug3, Bee Hoon Heng1, Vathsala Andaraman3, Fong-Seng Lim4 • 1Health Services & Outcomes Research department, National Healthcare Group (NHG), Singapore, 2Disease Management, NHG , 3Division of Nephrology, National University Hospital Health System, Singapore, 4NHG Polyclinics Introduction Methods Results Figure 4. GP's Awareness of CKD guidelines Chronic kidney disease (CKD) and kidney failure are reaching pandemic proportions in Singapore. The aging population, higher prevalence of diabetes and hypertension are some factors that contribute to the increasing incidence of kidney disease. The effects of these factors are likely to increase in the years to come.1 Recently specialist outpatient clinics (SOC’s) in Singapore are facing increasing pressure to handle more appointment requests than before due to the aging and growing population.2 The lead time between an appointment request and the actual visit tends to be longer because the growth of SOC capacity cannot catch up with the increasing demand. Analysis of the workload and case mix of the renal specialist outpatient clinics (SOC’s) in Singapore General Hospital revealed that up to 30% of the patients seen had early kidney disease that could be managed in the community by family physicians.3 To ensure efficient and quality healthcare delivery for all, the healthcare system must ensure that patients are ‘right-sited’, i.e. they receive care in the most appropriate care setting for their medical needs, with the most efficient use of resources. This study aims to identify factors influencing screening and management of CKD among primary care physicians (PCP) in Singapore, in order to plan programme(s) to encourage their participation in the right-siting program. Three hundred and two GPs completed the questionnaire; response rate was 25%. Majority of the respondents were males (70%) and Chinese (92%) with their median duration of practice being 18 years. Of these, 86% reported screening patients for CKD, 76% attend to less than 10 CKD patients per year (Figure.2), 50% were confident of managing patients with CKD stage I, and 33% and 13% were confident in managing CKD stage 2 and stage 3, respectively (Table.1). Ten percent of GPs reported using serum creatinine, urinalysis (UFEME), random urine albumin creatinine ratio or urine creatinine ratio for CKD screening. Thirty eight percent of GPs are aware of CKD guidelines; only 27.5 % of them specified definite guidelines (Figure.4). Majority of GPs (64%) agreed that right-siting of early CKD patients would ease congestion at SOC clinics (Figure.3). Obstacles to CKD management that were listed by the GPs included the lack of patient trust, experience and communication with the specialist, and inability of the patient to pay. Motivational drivers of GPs towards CKD management included access to patient information, co-management with renal physician, more interaction with renal physicians and adequate remuneration for the time spent in managing CKD. A survey was conducted among the 1,202 GPs registered in the National Healthcare Group (NHG) GP Partner database (Figure.1). A questionnaire was developed in collaboration with experts in nephrology and general practice to achieve the study objectives. It covered knowledge about screening tests for CKD, awareness of CKD guidelines, confidence in managing CKD stage 1 - 3, and their opinion about right-siting CKD care from SOC’s to primary care. The questionnaire was faxed to the physicians and followed up with three telephonic reminders. Data was collected between April 2010 and September 2010. Conclusions Figure 2. CKD patients treated & managed per year The survey has identified factors that prevent and facilitate the wider acceptance of CKD right-siting by both the patients and the GPs. GPs screen for CKD, however their awareness of CKD guidelines is limited. Opportunities exist for improvement, which includes increasing physician recognition of CKD, awareness of the evidence-based CKD guidelines, improving collaborative care with nephrology and reimbursement for the patient and the provider. References Figure 1. Distribution of the surveyed GP’s Table 1. GP’s confidence in managing CKD (Stage I, II & III) Figure 3. GP's opinion on right-siting CKD care • Vathsala A. Twenty-five facts about kidney disease in Singapore: in remembrance of World Kidney Day.Ann Acad Med Singapore. 2007 Mar;36(3):157-60. • http://www.moh.gov.sg/mohcorp/pressreleases.aspx?id=964 [24 March 2010] • Annual Report (2006). Centre for Health Services Research (CHSR).Available at http://www.singhealth.com.sg/research/healthservicesresearch/hsrannualreport/documents/chsrannualreport.pdf, Date accessed: May 12, 2011.