Journal of General Internal Medicine

, Volume 34, Issue 7, pp 1228–1235 | Cite as

Primary Care Physicians’ Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study

  • Raquel C. GreerEmail author
  • Yang Liu
  • Kerri Cavanaugh
  • Clarissa Jonas Diamantidis
  • Michelle M. Estrella
  • C. John Sperati
  • Sandeep Soman
  • Khaled Abdel-Kader
  • Varun Agrawal
  • Laura C. Plantinga
  • Jane O. Schell
  • James F. Simon
  • Joseph A. Vassalotti
  • Bernard G. Jaar
  • Michael J. Choi
  • On behalf of the National Kidney Foundation Education Committee
Original Research



Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal.


We aimed to identify PCPs’ perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface.

Study Design

Qualitative study

Setting and Participants

Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA


We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes.

Key Results

Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for “better communication tools” (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration.


Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.


chronic kidney disease primary care nephrology co-management qualitative research 



This work was supported by the National Kidney Foundation of Maryland, the National Kidney Foundation, and the National Institutes of Health grant K23DK094975 (Greer), K23DK090304 (Abdel-Kader), and R01DK103935-01A1 (Cavanaugh). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

The Johns Hopkins Medicine Institutional Review Board approved the study protocol.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Raquel C. Greer
    • 1
    • 2
    Email author
  • Yang Liu
    • 1
    • 3
  • Kerri Cavanaugh
    • 4
    • 5
  • Clarissa Jonas Diamantidis
    • 6
  • Michelle M. Estrella
    • 7
  • C. John Sperati
    • 8
  • Sandeep Soman
    • 9
  • Khaled Abdel-Kader
    • 4
    • 5
  • Varun Agrawal
    • 10
  • Laura C. Plantinga
    • 11
    • 12
  • Jane O. Schell
    • 13
  • James F. Simon
    • 14
  • Joseph A. Vassalotti
    • 15
    • 16
  • Bernard G. Jaar
    • 1
    • 8
    • 17
    • 18
  • Michael J. Choi
    • 8
  • On behalf of the National Kidney Foundation Education Committee
  1. 1.The Welch Center for Prevention, Epidemiology, and Clinical ResearchBaltimoreUSA
  2. 2.Division of General Internal Medicine Johns Hopkins UniversityBaltimoreUSA
  3. 3.Johns Hopkins Medicine International, Johns Hopkins Medical InstitutionsBaltimoreUSA
  4. 4.Vanderbilt Center for Kidney DiseaseVanderbilt University Medical CenterNashvilleUSA
  5. 5.The Division of NephrologyVanderbilt University Medical CenterNashvilleUSA
  6. 6.Divisions of General Internal Medicine and NephrologyDuke University School of MedicineDurhamUSA
  7. 7.Kidney Health Research Collaborative, Department of MedicineKidney Health Research Collaborative, Department of Medicine, University of California, San Francisco and San Francisco VA Health Care SystemSan FranciscoUSA
  8. 8.Division of Nephrology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA
  9. 9.Division of Nephrology and HypertensionHenry Ford HospitalDetroitUSA
  10. 10.Division of Nephrology and HypertensionUniversity of VermontBurlingtonUSA
  11. 11.Department of MedicineEmory UniversityAtlantaUSA
  12. 12.Department of EpidemiologyEmory UniversityAtlantaUSA
  13. 13.Section of Palliative Care and Medical Ethics, Renal-Electrolyte University of Pittsburgh School of MedicineUniversity of Pittsburgh Medical CenterPittsburghUSA
  14. 14.Department of Nephrology and Hypertension, Glickman Urologic and Kidney InstituteCleveland ClinicClevelandUSA
  15. 15.National Kidney FoundationNew YorkUSA
  16. 16.Icahn School of Medicine at Mount SinaiNew YorkUSA
  17. 17.Nephrology Center of MarylandBaltimoreUSA
  18. 18.The Welch Center for Prevention, Epidemiology, and Clinical Research InstitutionsBaltimoreUSA

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