Table 1.

Barriers and suggested interventions to integrate routine kidney genomic testing into clinical practice

Clinician reported barrier	CFIR construct	Description	Intervention applied in practice	Impact on the clinical setting
Before-referral period
Delay in referrals and uptake by nephrologists not engaged with kidney genetics	Inner setting	Culture and implementation climate	Education initiatives	Earlier referrals to kidney genetics clinics
The inequity of referral for testing	Inner setting	Structural characteristics and underpinnings of inequity	Education initiatives	Increased referrals and reach of genomic testing
Variable access to testing between jurisdictions	Inner setting	Structural characteristics and readiness for implementation	Education initiatives	Equitable access to genomic testing in kidney disease
Nephrologists are unsure whom to refer to	Characteristics of individual	Knowledge and beliefs about the intervention	Education initiatives	Increased number of appropriate referrals
Nephrologists uncertain of the benefit of referral	Intervention characteristics	Evidence Strength & Quality	Education initiatives	Increased number of appropriate referrals
Poor community and consumer understanding of genomic testing	Process	Engaging	Engagement with communities and public engagement events	Increased utilization of genomic testing and application of findings
Patients and the general community are uncertain of the benefits of referral.	Intervention characteristics	Evidence strength & quality	Engagement with communities and public engagement events	Increased utilization of genomic testing and application of findings
Post referral-pretesting period
The logistics of testing are too complicated to incorporate into clinics	Intervention characteristics	Complexity	Process simplification	Increased utilization of genomic testing
Nephrologists did not know how to order tests or prioritize patients for testing.	Inner setting	Knowledge and beliefs about the intervention, self-efficacy	Education initiatives	Increased utilization of genomic testing
Clinicians are unsure of which genes to test, which method to use	Inner setting and characteristics of individual	Access to knowledge and information	Developing standardized gene lists and recommended method	Increased utilization of genomic testing
Delay in sequencing	Process	Executing	Variant prioritization - meetings initiated	Earlier genomic testing
Variation in access to and cost of testing	Intervention characteristics	(Perceived) Cost
No consistent clinical genetics support	Inner setting	Available resources	Engagement with clinical genetics services and national consortia; Identification of clinical geneticist champions	Increased clinical genetics department engagement
The remote location of the clinical geneticist	Inner setting	Available resources	Telehealth clinics, remote/visiting clinics	Increased access to clinical geneticists
The remote location of patients who may lack literacy	Outer setting	The patient's needs and resources
Missed appointments to clinics reduce sustainability.	Outer setting	The patient's needs and resources
Unable to access clinical geneticist during clinic	Inner setting	Available resources
No secure funding for the multidisciplinary team (MDT) model of care	Inner setting	Available resources	Engagement with clinical services for the redesign of existing activities and demand; clinical champions engaged	Sustained operation of MDT models of care within existing resourcing
Variable hospital funding for tests	Outer setting	External policy and incentives
Post-testing period
Long turn-around-time for sequencing and analysis	Intervention characteristics	Complexity	Variant prioritization - meetings initiated	Earlier genomic testing
Delay in return of results	Inner setting	Available resources	MDT results meetings and review systems	Improved accountable delivery of results to consumers
Results difficult for nephrologists without specific training to interpret/apply	Intervention characteristics	Complexity	Targeted and sustained multimodal education supported by the National Strategic Action Plan for Kidney Disease	Perceived improving clinician confidence
Results not received by the referring doctor	Process	Executing	Upfront information for doctors	Clinical translation of genomic testing
Unclear recommendations to referrer regarding the clinical application of findings	Intervention characteristics	Complexity	Facilitated interpretation and clinician guidance in interprofessional communication	Supported referrer actioning of result outcomes
Difficulty in understanding the implications of a variant of uncertain significance	Characteristics of individual	Knowledge and beliefs about the intervention and self-efficacy
Delay or failure of whom to clinically act on genetic findings	Characteristics of individual	Knowledge and beliefs about the intervention	Upfront information for doctors and patients	Clinical translation of genomic testing

CFIR, Consolidated Framework for Implementation Research; MDT, multidisciplinary team.