Table 2.

Barriers in implementation of KDIGO CPG on monitoring biochemical parameters of CKD-MBD

	Japan	Korea	Taiwan	Singapore	China	Hong Kong	Thailand	Malaysia
Government/policy level	Nil	Nil; in Korea, reimbursement on monitoring covers CKD from G3a	Not a barrier as there is structured CKD program with standardized monitoring frequency with incentive available for referral of CKD G3b to nephrologist	No policy requirements for monitoring of biochemical parameters of CKD-MBD	Diverse policies in different parts of the country—urban vs. rural	Lack of structured CKD program	Late referral of patients with CKD to nephrologists	Lack of government policy on referral of CKD3a and 3b patients, hence patients with CKD are cared for mostly by primary care physicians
Hospital level	Nil	Nil	Nil	Heavy workload in nephrology unit, and reminder needed on timing of monitoring	Many institutions in rural areas do not have biochemical tests available	Cost of PTH testing high and restrictions on PTH testing in hospitals	Nil	Lag time in results reporting as tests are processed in batches; results may not be acted upon until much later
Physician level	Low awareness of the need to monitor PTH	Low awareness of the need to institute frequent monitoring	CKD guidelines require referral of CKD G3b to nephrologists	CKD G3a is mostly managed by primary care physicians and PTH test may not be performed	Low awareness of the need for regular monitoring; goals of management is cost containment	A large proportion of predialysis patients may be managed in the private sector; lack of education of general and primary care physicians	CKD G3a–G4 are mostly managed by family or general physicians, thus PTH and alkaline phosphatase testing not likely being done	Non-nephrologists may not be aware of the need for regular monitoring
Patient level	Nil	Nil	Nil	Patients may refuse tests in private settings because they require out-of-pocket costs	Out-of-pocket costs; noncompliance of follow-up, which will affect monitoring frequency	Nil	Out-of-pocket costs	Nil
Reimbursement issues	Nil	Nil	Nil	Tests not fully reimbursed, but may be offset by certain schemes	Reimbursement may not be available in some hospitals	Nil	PTH/alkaline phosphatase testing may not be reimbursed, depending on the reimbursement policy	Reimbursement may not be available for some institutions

CKD-MBD, chronic kidney disease–mineral bone disorder; CPG, clinical practice guidelines; KDIGO, Kidney Disease: Improving Global Outcomes; PTH, parathyroid hormone.