Knowledge and competence of primary healthcare physicians in the management of diabetes-related chronic kidney disease

Abstract

BACKGROUND:

Diabetes mellitus (DM) is a primary cause of chronic kidney disease (CKD), a significant and growing global health issue. Primary healthcare physicians (PHPs) are crucial in detecting, managing, and preventing CKD, but many lack the necessary knowledge and skills to effectively diagnose and manage the disease. This study assessed the knowledge and competence of PHPs in managing diabetes-related CKD.

MATERIALS AND METHODS:

This cross-sectional study was conducted among all Primary Healthcare Physicians (PHPs) working at Primary Healthcare Center (PHC) in King Abdulaziz Medical City of the National Guard, Jeddah, Saudi Arabia. An online questionnaire was sent to all PHPs and data were collected from January 2024 to February 2024. Data analysis performed utilizing RStudio (version 4.3.1). Categorical variables were expressed as frequencies and percentages, whereas mean and standard deviations were computed for continuous variables. Kruskal–Wallis rank sum test was used to determine differences in confidence scores across various demographic and occupational characteristics. A multivariable linear regression analysis was performed to identify factors related to confidence.

RESULTS:

Of 141 PHPs, 122 filled online questionnaire yielding a response rate of 86.5%. responded. The majority (90.2%) were 18–45 years of age, 68.0% were qualified as family physicians, 38.0% belonged to the specialized poly clinic, and 54.9% had less than 5 years of experience. PHPs showed a varied levels of confidence and knowledge. While 76.2% were confident about the stages of kidney disease and 65.6% acknowledged the importance of the urine albumin-creatinine ratio (uACR) test, 58.1% were uncertain of interpreting uACR results and CKD diagnostic criteria. More than 60.0% were uncertain of the treatment steps postdiagnosis and prediction of CKD prognosis. Age, qualification, specialization in family medicine, and clinic affiliation were significantly related to confidence levels.

CONCLUSION:

The study underscores notable gaps in PHPs' knowledge and confidence concerning CKD screening, diagnosis, and management. Continuous education and targeted interventions are essential for the improvement of PHPs' competence and patient outcomes in the management of CKD.

Introduction

Diabetes mellitus (DM), a primary cause of chronic kidney disease (CKD),[1] is a growing public health concern worldwide. In Saudi Arabia, it is estimated that 9892/100,000 individuals are affected by CKD.[2] CKD is characterized by a gradual loss of kidney function, leading to serious health complications such as cardiovascular disease (CVD), anemia, and bone disorders. Primary healthcare physicians (PHPs) play a crucial role in detecting, managing, and preventing CKD.[3] However, research shows that many PHPs lack the necessary knowledge and skills to diagnose and manage CKD effectively.[4]

Several studies have explored PHPs' knowledge of diabetes-related CKD. For example, a study in Poland, in a survey to assess PHPs' understanding of CKD, found that only 2.4% of PHPs could answer all questions correctly, indicating a lack of familiarity with CKD’s diagnostic criteria, risk factors, and progression. In addition, around 25% of PHPs did not recognize the significance of albuminuria for diagnosis, and 63.1% failed to identify the correct risk factors for CKD. Younger and less experienced practitioners exhibited a notable deficiency in knowledge.[5] Similarly, a study in Pakistan revealed that only about 40% and 29% of general practitioners could correctly identify the target systolic and diastolic blood pressure for CKD patients, respectively. Only 38% selected estimated glomerular filtration rate (eGFR) as a method of measuring kidney function and detecting CKD. While most general practitioners recognized DM and hypertension as risk factors, they were unaware of other risk factors, and less than half knew the appropriate time to refer a patient to a nephrologist.[6]

PHCPs’ knowledge of diabetes-related CKD management varies in different countries and regions, but there is a common knowledge gap. Continuous medical education programs and targeted interventions are necessary to improve PHPs' knowledge and perceptions of CKD management and ultimately enhance patient outcomes. This study’s aim was to assess PHPs' knowledge and competence in managing CKD in a local setting.

Materials and Methods

This study employed a cross-sectional design with consecutive sampling, targeting all documented PHPs involved in managing CKD. Ethical approval was obtained from the Institutional Review Board (IRB) of King Abdullah International Medical Research Center, Jeddah vide Letter No. IRB/2910/23 dated 23/11/2023 and written informed consent was taken from all participants in the study.

Data collection was done by using a validated questionnaire adapted from previous research to assess physicians’ knowledge and confidence levels.[4] Besides, an online Google Form was utilized to gather demographic- and practice-related information. The survey developed by the Primary Care Diabetes Europe research group had been validated and piloted, according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines.[7] The study was conducted from January 2024 to February 2024.

The inclusion criteria consisted of PHPs, family medicine specialists, trainees, and general practitioners. Data collection involved all PHPs in the Primary Healthcare Center (PHC) in King Abdulaziz Medical City of the National Guard, Jeddah, Saudi Arabia (n = 141). Online surveys were sent through e-mail; 121 physicians returned completed questionnaires giving a response rate of 86.5%.

The study assessed three main domains: Screening and diagnosis of CKD, CKD staging and clinical presentation, and management strategies for diabetic kidney disease (DKD). The domains included screening and diagnosis of CKD, CKD staging, clinical presentation, and prognosis, as well as management strategies for DKD. Each domain comprised specific items coded from responses ranging from “Not confident about this subject”[1] to “Fully confident in this area and could teach others.”[5] The screening and diagnosis domain comprised six items such as understanding the significance of urine albumin-creatinine ratio (uACR) testing and interpreting urea and electrolyte test results. CKD staging, clinical presentation, and prognosis included six items such as recognizing signs and symptoms of advanced CKD and understanding common risks and complications associated with diabetes and kidney disease. Finally, DKD management domain involved five items such as selecting appropriate management strategies and understanding the role of medications such as renin–angiotensin–aldosterone system inhibitors (RAAS-Is) and sodium-glucose cotransporter-2-inhibitors (SGLT2-Is). Confidence scores for each domain were calculated by summing up the coded items within each domain, accounting for scores ranging between 6 and 30 for the first and second domains and between 5 and 25 for the third domain so that higher scores indicated higher confidence levels.

We conducted data analysis utilizing RStudio version 4.3.1 (Integrated Development Environment for R, Boston, MA). Categorical variables were expressed as frequencies and percentages, whereas mean and standard deviations were employed for continuous variables. Internal consistency was evaluated using Cronbach’s alpha coefficients. To examine differences in confidence scores across various demographic and occupational characteristics, a Kruskal–Wallis rank sum test was utilized. Furthermore, a multivariable generalized linear regression analysis was performed to identify independent predictors of confidence, incorporating variables found significantly associated in the inferential analysis. Statistical significance was determined at P = 0.05.

Results

The responses of a total of 122 respondents were analyzed in the current study. The majority of participants (90.2%) were 45 years or younger. More than two-third were qualified as family physicians (68.0%). The largest proportion of participants belonged to the specialized poly clinic (38.0%). Regarding years of clinical experience, the highest frequency was in the category of participants with <5 years of experience (54.9%) [Table 1].

Table 1.

Demographic and occupational characteristics of primary healthcare physicians at King Abdulaziz Medical City, Jeddah, Saudi Arabia (n=122)

Characteristics	N (%)
Age
18–30	55 (45.1)
30–45	55 (45.1)
45–60	12 (9.8)
What is your qualification?
Family medicine resident	31 (25.4)
Family physician	83 (68.0)
Family medicine specialized in diabetes	7 (5.7)
General practitioner	1 (0.8)
Which National Guard Primary Healthcare Center do you belong to?*
Alsharaie Clinic	4 (3.3)
Bahra Clinic	9 (7.4)
Iskan Jeddah Clinic	13 (10.7)
IskanTaif Clinic	6 (5.0)
Protocol Clinic	1 (0.8)
Resident	38 (31.4)
Specialized Poly Clinic	46 (38.0)
Staff Clinic	4 (3.3)
Years of clinical experience
<5	67 (54.9)
5–10	22 (18.0)
>10	33 (27.0)

*The variable had one missing value. n (%)

The internal consistency analysis using Cronbach’s alpha yielded high-reliability coefficients for all three domains assessed. For the screening and diagnosis of CKD, the Cronbach’s alpha coefficient was 0.923, indicating strong internal consistency among the six items in this domain. Similarly, for CKD staging, clinical presentation, and prognosis, the Cronbach’s alpha coefficient was 0.927, suggesting high internal consistency among the six items within this domain. In addition, for CKD management, the Cronbach’s alpha coefficient was 0.921, indicating strong internal consistency of the five items evaluated in this domain.

Based on the combined responses of participants’ confidence to practice in a given area without support or full confidence in the area, the majority of participants expressed confidence in their knowledge of the stages of kidney disease according to eGFR (76.2%), and a considerable proportion felt confident in their understanding of the significance and importance of urine albumin-creatinine ratio (uACR) testing in individuals living with diabetes (65.6%). However, there was notable uncertainty (lowest combined percentages of “Confident to practice in this area without support” or “Fully confident in this area and could teach others”) in participants regarding their ability to interpret uACR results (58.1%), their knowledge of the criteria for the diagnosis of CKD and DKD (52.4%), and screening methods for CKD in primary care (56.6%) [Figure 1].

Figure 1.

Primary healthcare physicians' responses regarding the screening and diagnosis of chronic kidney disease. uACR: Urine albumin-creatinine ratio

In the multivariable linear regression analysis, significant associations were found between qualification and screening and diagnosis of CKD. Specifically, respondents aged 30–45 years were more likely to be confident in the screening and diagnosis of CKD (OR = 4.28, P = 0.004). Furthermore, participants with a specialization in family medicine (OR = 2.86, P = 0.046) and family medicine who had specialized in diabetes (beta = 7.90, P = 0.001) showed a substantially higher confidence level compared to family medicine trainees, serving as the reference group. In addition, participants from the Bahra Clinic exhibited significantly higher confidence levels in screening and diagnosing CKD (OR = 5.81, P = 0.039) compared to those from the Alsharaie Clinic, the reference group [Table 2].

Table 2.

Mean confidence scores and the results of multivariable regression analysis for the predictors of overall confidence scores in the domain of screening and diagnosis of chronic kidney disease

Characteristics	Confidence scores		Multivariable regression
	Mean±SD	P-value	β	95% CI	P-value
Age
18–30	19.2±4.6	<0.001	Reference	Reference
30–45	25.0±5.2		4.28	1.45–7.11	0.004
45–60	25.2±4.5		3.14	−1.32–7.60	0.170
What is your qualification?
Family medicine resident	18.1±4.2	<0.001	Reference	Reference
Family physician	23.6±5.2		2.86	0.09–5.63	0.046
Family medicine specialized in diabetes	29.0±1.9		7.90	3.32–12.5	0.001
General practitioner	12.0±NA		−9.56	−19.2–0.13	0.056
Which National Guard Primary Healthcare Center do you belong to?
Alsharaie Clinic	20.5±3.1	<0.001	Reference	Reference
Bahra Clinic	28.2±3.3		5.81	0.35–11.3	0.039
Iskan Jeddah Clinic	23.1±4.9		3.59	−1.50–8.68	0.170
IskanTaif Clinic	25.2±4.4		3.80	−2.13–9.73	0.212
Protocol Clinic	30.0±NA		8.47	−1.75–18.7	0.107
Resident	19.0±4.3		2.51	−2.55–7.57	0.334
Specialized Poly Clinic	23.9±5.6		2.14	−2.50–6.79	0.368
Staff Clinic	17.5±7.2		−1.39	−7.75–4.98	0.670
Years of clinical experience
<5	20.5±5.2	<0.001	Reference	Reference
5–10	23.6±5.9		−1.80	−4.85–1.26	0.252
>10	25.6±4.8		0.05	−2.92–3.01	0.975

SD=Standard deviation, CI=Confidence interval, NA=Not available

Approximately half (46.8%) of participants were confident in recognizing the possible signs and symptoms of more advanced CKD, and a significant proportion felt confident in their understanding of kidney disease as a risk multiplier, increasing the risk of CVD and other complications, and the interconnectivity of the renal system with CVD and diabetes (45.9%). In addition, a considerable segment felt confident in their awareness of common risks and complications for people living with diabetes and kidney disease (41%). However, there was notable uncertainty among participants regarding their knowledge of appropriate next steps with regard to treatment after diagnosis (37.7%) and their understanding of how to predict CKD prognosis using albuminuria and eGFR categories (28.7%) [Figure 2].

Figure 2.

Primary healthcare physicians' responses regarding chronic kidney disease staging, clinical presentation, and prognosis. CKD: Chronic kidney disease

In the multivariable analysis, participants with a specialization in family medicine and in diabetes exhibited significantly higher levels of confidence (OR = 5.51, P = 0.023) than family medicine trainees as the reference group. Moreover, participants from the Bahra Clinic demonstrated significantly higher confidence levels in CKD staging, clinical presentation, and prognosis (OR = 7.71, P = 0.008) compared to those from the Alsharaie Clinic, the reference group [Table 3].

Table 3.

Mean confidence scores and the results of multivariable regression analysis for the predictors of overall confidence scores in the domain of chronic kidney disease staging, clinical presentation, and prognosis

Characteristics	Confidence scores		Multivariable regression
	Mean±SD	P-value	β	95% CI	P-value
Age
18–30	16.5±4.4	<0.001	Reference	Reference
30–45	22.5±5.5		2.90	0.00–5.80	0.052
45–60	23.5±6.0		2.17	−2.40–6.74	0.354
What is your qualification?
Family medicine resident	15.6±3.5	<0.001	Reference	Reference
Family physician	21.0±5.8		0.89	−1.95–3.74	0.539
Family medicine specialized in diabetes	26.1±4.7		5.51	0.82–10.2	0.023
General practitioner	15.0±NA		−2.88	−12.8–7.06	0.572
Which National Guard Primary Healthcare Center do you belong to?
Alsharaie Clinic	18.8±4.6	<0.001	Reference	Reference
Bahra Clinic	27.7±4.3		7.71	2.11–13.3	0.008
Iskan Jeddah Clinic	19.5±4.5		1.31	−3.91–6.52	0.625
IskanTaif Clinic	21.5±5.4		2.60	−3.49–8.68	0.405
Protocol Clinic	29.0±NA		8.40	−2.07–18.9	0.119
Resident	15.7±3.3		−0.76	−5.95–4.44	0.776
Specialized Poly Clinic	21.6±5.8		1.76	−3.01–6.52	0.471
Staff clinic	17.8±6.1		0.40	−6.13–6.93	0.904
Years of clinical experience
<5	17.6±4.9	<0.001	Reference	Reference
5–10	20.5±5.6		−2.36	−5.49–0.77	0.143
>10	24.1±5.6		1.51	−1.54–4.55	0.334

SD=Standard deviation, CI=Confidence interval, NA=Not available

The majority of participants were confident in their understanding of blood pressure targets (64.8%) and the understanding of the use of treatments such as angiotensin-converting enzyme inhibitors (ACE-Is) or angiotensin II receptor blockers and their renal benefits (56.5%). However, there was notable uncertainty among participants in their knowledge of the management and role of RAAS-Is and SGLT2-Is and newer agents for DKD (41%), and their ability to select appropriate management to prevent or slow down the progression of CKD (41.8%) [Figure 3].

Figure 3.

Primary healthcare physicians' responses regarding chronic kidney disease management. DKD: Diabetic kidney disease, CKD: Chronic kidney disease

In the multivariable regression analysis for DKD management, participants with a specialization in family medicine and in diabetes showed significantly higher levels of confidence (OR = 6.70, P = 0.002) than family medicine residents, serving as the reference group [Table 4].

Table 4.

Mean confidence scores and the results of multivariable regression analysis for the predictors of overall confidence scores in the domain of chronic kidney disease management

Characteristics	Confidence scores		Multivariable regression
	Mean±SD	P-value	β	95% CI	P-value
Age
18–30	15.9±4.0	<0.001	Reference	Reference
30–45	19.5±4.7		1.39	−1.12–3.89	0.281
45–60	20.1±4.8		0.43	−3.52–4.37	0.833
What is your qualification?
Family medicine resident	14.9±3.7	<0.001	Reference	Reference
Family physician	18.7±4.5		1.10	−1.35–3.56	0.380
Family medicine specialized in diabetes	23.7±2.0		6.70	2.65–10.8	0.002
General practitioner	13.0±NA		−2.01	−10.6–6.56	0.646
Which National Guard Primary Healthcare Center do you belong to?
Alsharaie Clinic	19.0±2.2	<0.001	Reference	Reference
Bahra Clinic	23.3±3.2		4.32	−0.51–9.16	0.082
Iskan Jeddah Clinic	17.7±4.4		−0.28	−4.79–4.22	0.902
IskanTaif Clinic	18.0±5.6		0.16	−5.09–5.42	0.951
Protocol Clinic	25.0±NA		5.88	−3.16–14.9	0.205
Resident	15.1±3.5		−2.36	−6.84–2.13	0.305
Specialized Poly Clinic	19.2±4.6		−0.24	−4.36–3.87	0.909
Staff Clinic	15.8±5.1		−1.39	−7.03–4.25	0.629
Years of clinical experience
<5	16.7±4.2	<0.001	Reference	Reference
5–10	17.6±5.1		−3.16	−5.87–0.45	0.224
>10	20.8±4.5		0.51	−2.11–3.14	0.702

SD=Standard deviation, CI=Confidence interval, NA=Not available

Discussion

On account of the crucial role of PHPs in the early detection and management of CKD, we examined their proficiency in managing CKD in PHCs through an online survey in our study. The findings revealed varying levels of confidence of participants regarding CKD management, with higher confidence levels noted in older physicians and those who had specialized in family medicine or diabetes. This contrasts with previous research indicating that resident physicians exhibited higher average knowledge scores on CKD compared to those with more years of practice.[4,5]

The majority of participants declared they were confident in their understanding of the significance of testing uACR in diabetics and the CKD stages based on eGFR. Similarly, a study in Saudi Arabia found that two-thirds of physicians were knowledgeable about the five CKD stages.[1] Furthermore, a study in Jimma town found that many PHPs had good knowledge of CKD stages.[4] However, there was a lack of conviction with regard to screening and diagnostic criteria for DKD and CKD, as well as the interpretation of uACR results. Our participants’ comprehension of CKD complications mirrors findings from studies conducted by Gheith et al., and Choukem et al.[1,8]

There were notable areas of vagueness regarding the knowledge of screening and diagnostic criteria for DKD and CKD, as well as the interpretation of uACR results. In a similar study conducted in Poland, only 78.4% recognized an accurate diagnostic criterion for CKD. These findings are noteworthy as they may indicate a potential under-identification of individuals with or at risk of developing CKD. Similarly, another study in the United Arab Emirates highlighted suboptimal utilization of accurate screening tests for CKD by physicians who were not nephrologists.[4] Furthermore, a study in Saudi Arabia identified a knowledge gap concerning CKD screening, revealing that the majority of participants, including family, general, and internal medicine physicians, overscreened their patients for CKD at intervals of approximately 6 months.[1] Since screening for CKD should be personalized according to individual comorbidities and risk factors, it is important to note that less than half the physicians exhibited little confidence in initiating agents with specific benefits in DKD, such as SGLT1-Is, and in selecting appropriate agents to help prevent or halt CKD progression. In contrast, a European study found that one-third of respondents were fully confident in selecting the appropriate management strategy, including initiating newer agents, for CKD patients.[9]

Most of our participants demonstrated knowledge of the blood pressure targets in CKD patients, which aligns with findings from a study evaluating the knowledge of clinical practice guidelines for CKD in internal medicine residents. In contrast, Yaqub et al., discovered that approximately 40% and 29% of general practitioners in their study recognized the correct systolic and diastolic blood pressure targets, respectively.[6]

Furthermore, a notable number of physicians in our study demonstrated confidence in their knowledge of the renal benefits of RAAS-Is in DKD. Conversely, Al Shamsi et al., discovered that only one-third of nonnephrologist physicians prescribed RAAS-Is to CKD patients.[10]

Moreover, a noticeable lack of confidence was noted in nearly one-third of participants regarding the prediction of the prognosis based on albuminuria and eGFR categories according to KDIGO guidelines. Similarly, approximately 37% of family physicians and nonnephrology internists in a study conducted in West Africa were unaware of any guidelines for the management of CKD.[11] However, a European study showed that only a mere 11% lacked confidence in predicting CKD prognosis based on established guidelines.[12] A study conducted in Saudi Arabia revealed that two-thirds of the participants recognized eGFR and creatinine clearance as indicators of kidney function.[7] In contrast, a study of general practitioners in Pakistan identified serum creatinine as the preferred method for predicting kidney function.[6]

The evidence presented in this study involving PHPs and other healthcare professionals engaged in managing CKD patients highlight a knowledge gap in screening, accurately identifying, and managing CKD and its complications.

In a study of the barriers to the management of comorbid diabetes and CKD in primary healthcare settings, it was discovered that 34.8% of participants were uncertain about the correct definition of CKD, and a significant number expressed the desire to be instructed further on the topic. In addition, the majority of participants expressed interest in managing DKD in primary healthcare with specialist assistance.

Similarly, in a study assessing the knowledge of CKD management in Jimma town, many care providers also expressed a strong interest in deepening their understanding of the subject.[4] While we did not directly assess the respondents’ desire for educational interventions to enhance their competence in managing CKD, our findings suggest the presence of gaps and areas for improvement in PHPs' knowledge of CKD.

This study represents the first attempt to evaluate PHPs' awareness and proficiency in diagnosing and managing diabetic DKD in National Guard PHCs in Saudi Arabia. The utilization of a validated questionnaire and the high response rate of 86.5% were significant strengths of this study. However, the results may not be applicable to all PHPs in Saudi Arabia, as the study only focused on National Guard PHPs in the western region of the country. Nonetheless, these findings can be employed to enhance knowledge about diabetes-related CKD among PHPs and thereby improve the management of DKD patients and their overall prognosis. Future research involving a broader spectrum of PHPs beyond those in National Guard PHCs would provide a more comprehensive understanding of PHPs' confidence in managing DKD patients. In addition, further investigation is warranted to identify barriers that contribute to PHPs' suboptimal confidence in managing these patients.

Conclusion

Although the majority of participants recognized the significance of uACR testing in DKD patients, over half of them struggled with interpreting its results. Besides, more than half of the respondents lacked confidence in their understanding of both the screening protocol and diagnostic criteria for DKD. Nonetheless, there was a notable correlation between higher qualifications of PHPs and confidence in screening and diagnosing DKD. Family consultants, especially those specialized in diabetes, exhibited more confidence in managing such cases compared to family medicine trainees.

Despite the awareness of the majority of participants of the renal benefits associated with ACE-Is and angiotensin receptor blockers, over 40% were unfamiliar with the role of agents such as RAAS-Is and SGLT2-Is in managing diabetes-related CKD. Therefore, it is imperative to identify effective interventions aimed at improving the management of DKD patients in PHCs.

Based on our research, we propose the development of comprehensive training programs that particularly target less experienced practitioners to enhance PHPs' ability to interpret uACR results and comprehend DKD screening protocols. Furthermore, studies should explore the impact of specialized diabetes training, improve knowledge of RAAS-Is and SGLT2-Is through focused educational initiatives, and evaluate the long-term effects of these interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.