ABSTRACT
Rationale & Objective: The measurement of cystatin C has been recommended to enhance chronic kidney disease (CKD) detection and risk stratification in clinical practice. This study gathered insights into the perceptions and experiences of clinical staff regarding the use of cystatin C in CKD detection within the Veterans Health Administration (VHA) system. Study Design: A qualitative approach was employed to explore barriers and facilitators of clinical staff regarding the use of cystatin C in CKD detection within the VHA system. The Organizational Theory of Implementation Effectiveness informed the development of a semistructured interview guide. Setting & Participants: Health care providers, nurses, and clinical pharmacists from the VHA systems in San Francisco, San Diego, and Houston were interviewed between October 2021 and May 2022. Exposures: Participants' experiences with cystatin C testing. Outcomes: Perceived barriers and facilitators to cystatin C testing. Analytical Approach: Participant responses from individual interviews were analyzed by a multidisciplinary team using rapid qualitative analysis methods. Results: Fourteen in-depth interviews were conducted across the 3 VHA systems. Ten of 11 providers worked in primary care. Five key barriers to using cystatin C for CKD detection were identified. These included lack of patient awareness of CKD testing, lack of provider awareness about cystatin C, knowledge barriers about cystatin C testing, unclear roles and ownership of CKD detection, and lack of clinic support to enhance CKD detection. Suggested interventions to overcome these barriers included educational and training programs, improved clinic workflows, and electronic health record aids to support CKD detection and use of cystatin C. Limitations: The results may not be generalizable to other health care systems outside the VHA. Conclusions: The findings indicate a need for targeted interventions such as educational and training programs, improved clinical workflows, and electronic health record aids to address barriers limiting the use of cystatin C in clinical practice for enhanced CKD detection.
This study assessed how clinical staff at the Veterans Health Administration (VHA) feel about using a test called cystatin C to help detect chronic kidney disease (CKD) earlier and more accurately. The research team spoke to healthcare providers, nurses, and clinical pharmacists in San Francisco, San Diego, and Houston between October 2021 and May 2022. We conducted 14 detailed interviews to understand the challenges and opportunities in using cystatin C for CKD detection. We found that participants often lacked awareness of CKD and the benefits of testing with cystatin C. There were also gaps in knowledge about how to use the test effectively, confusion over who should be responsible for CKD detection, and a need for better support within clinics to use cystatin C. To address these issues, there should be more educational programs for both staff and patients, improvements in clinic processes, and enhancements to electronic health records to better support CKD detection using cystatin C. However, the results from this study might not apply to other healthcare systems outside the VHA.
ABSTRACT
BACKGROUND: There are major gaps in the implementation of guideline-concordant care for persons with chronic kidney disease (CKD). The CKD Cascade of Care (C3) initiative seeks to improve CKD care by improving detection and treatment of CKD in primary care. METHODS: C3 is a multi-modal initiative deployed in three major academic medical centers within the Department of Veterans Affairs (VA) Health Care System: San Francisco VA, San Diego VA, and Houston VA. The main objective of the first phase of C3 described in this protocol is to establish the infrastructure for universal CKD detection among primary care patients at high-risk for CKD with a triple-marker screen comprising cystatin C, creatinine, and albuminuria. Across the three sites, a comprehensive educational intervention and the integration of primary care-based clinical champions will be employed with the goal of improving CKD detection and treatment. The San Francisco VA will also implement a practice-facilitation intervention leveraging telehealth and health informatics tools and capabilities for enhanced CKD detection. Parallel formative evaluation across the three sites will assess the feasibility and acceptability of integrating cystatin C as part of routine CKD detection in primary care practice. The effectiveness of the interventions will be assessed using a pre-post observational design for change in the proportion of patients tested annually for CKD. Secondary outcomes will assess change in the initiation of cardio-kidney protective therapies and in nephrology referrals of high-risk patients. DISCUSSION: The first phase of C3 is a multi-facility multi-modal initiative that aims to improve CKD care by implementing a triple-marker screen for enhanced CKD detection in primary care.
