Table 6.

Exemplar quotes illustrating enablers to diagnosis and management of CKD in primary care, by theme^a

Domain/theme	Quote
Beliefs about capabilities
Managing patient expectations during education	“I think if you try to set the expectations fairly quickly, then you know that certainly helps.” [27]
Relationship between primary care provider and patient	“Sometimes…if you just gave them time, if you just show them that you really, really care, they go to all the quality of the physician and nurses, then they start to trust you, then they actually start to actually listen to what you’re saying, and then we can have good discussions. So a lot of people will sort of turn around the initial ‘no, I want this, this, this, and that.” [27]
Beliefs about consequences
Prioritising patient quality of life	“It would have just been a burden to send [the patient] to another specialist, and explain all the story and inevitably the [nephrologist] says “oh let’s do a couple of extra investigations”…for some of these older people, it’s a marathon process.” [27]
Environmental context and resources
Access to laboratories	“We used to have a lab in our family practice unit, right in the same building and that really was helpful for our patients in terms of any sort of laboratory investigations, but yeah.” [31]
Access to nephrology	“it would make more sense for me as a non-palliative care doctor to be able to quickly access with a phone call somebody who has that information in their head right away” [27] “… if I’m really worried about something, I text the nephrologist I know real well and say…this is what’s going on, it’s in the record, and they get in” [8, 34]
Better access to support services	“Home care service in [a small population center] is very poor. .. they say that are too busy to provide additional services for seniors. Often patients end up in the [emergency room] ER and/or hospital when early intervention could prevent this. Palliative care in this region is also poor. I have taken it on myself to do home visits, etc. to help people at home as long as the patient and family are comfortable.” [37]
Financial incentives	“There had to be some sort of remuneration…so it makes it [CKD service] worth the time…. At the end of the day, we have to run a business and pay for staff so to be able to prioritize time for those different jobs you need to have some sort of income for it” [30]
Nephrology referral pathways	“The Nephrology Department can see the referrals coming in, so they can see how providers, in general, [treat] kidney disease. Are we reasonable with our referrals?...Are we sending people too early or too late? It would be nice to know are there places where there’s room for improvement. I want to know whether I’m doing a reasonable job or not” [26]
Patient education resources	“I had a nice little, laminated handout that came from Nephrology on guidelines and referrals. It has now gone missing, so it would be helpful to have that resent out again – it’s a very convenient and worthwhile thing to have” [26] “I’d love to see a promotion about the kidney class, so that clinicians are more aware of it. . . . if they’d promote the kidney class and say, in general these classes are offered at [these] various times and locations, etc. -. that would help primary care, because we inevitably get those types of questions” [26]
Raising patient awareness of services available	“It’s probably the fact that we don’t have ads on the radio saying go into pharmacy for this and the other…that’s the thing that makes people realize what your scope of business is” [30]
Technological improvements to identify and manage CKD	Automatic alerts (eg BP mgmt) would: “prompt people, even if they’re not fully educated about CKD, to make sure that they do a pretty comprehensive job of managing the disease.” [25]
Technological improvements to identify and manage CKD	“I think for me the most important thing would be just having a shared EMR where you can just look up that encounter very quickly” [8, 34] “I thought it was great [to have it automatically reported], because I didn’t have to try to manually calculate it. Prior I had been using kind of just ballpark numbers to try to guesstimate when I thought somebody’s renal function was starting to decline and if I needed to adjust medication. So, it was challenging because it added work to my day to have to manually do that or try to assess that.. . So it has made life easier for me to have it calculated” [26] “I think it’s a good tool. So the fewer steps that we have to do to get to the right answer, and the right thing to do, the better it is. I think the automatic calculator is quicker and better at math than I am, and more reliable. And so, it takes away some of the potential for error that I might have introduced by manually doing the calculations myself” [26]
Time/workload	“more time to discuss these issues with patients than the general practitioner and can listen and engage [with] the patient” [9]
Knowledge
Diagnosis of CKD supports a proactive approach to care	“... then you realise they also have CKD so it gives you the level of awareness. This patient has got ... is up the CKD spectrum and we need to be especially aware of how we intervene with their other morbidities.” [7]
Guidelines provide roadmap for care	“just to get that learning out there and to have a readily available tool to go “okay, for this symptom I’ll do this and for these symptoms I’ll do that,” it would be helpful.” [27] “I don’t think [guidelines] should determine [behaviour], but they should definitely guide it and direct it because it’s, again, research based and trying to follow that.” [31] “It was shown very clear when to refer, when you’ve got proteinuria when to refer, when, so that not everyone with proteinuria had to be referred and so the guidelines I thought were very clear and good.” [6]
Social influences
Collaboration between members of health care team	“It usually involves a multiple health professional team as well as the patient and their family. It rarely is just a patient–physician relationship.” [27] “I just want to be able to call someone for advice and not feel like I am wasting their time. I want a nephrologist to want to help me because I am in the trenches.” [37] “Shared care is essential especially given the workload of these patients. Not ‘my’ patient and not ‘your patient’. Our patient!” [37]
Social/professional role and identity
Capitalising on credibility from existing services	“What I did is your kidney study was there and then diabetes study we started in the pharmacy, so we linked both together and that has been better. So the same person, we can sometimes do both studies.” [30]
Clear delineation of healthcare provider roles	“I can just send tasks to certain nurses or support staff just to follow back up with them and ask them to order whatever I need to be done.” [31] “As soon as we started teaching the staff members, you know make sure that you ask them this, then it became a lot easier” [30]

^aIn addition to the themes listed in the table, the following theme was identified in the primary studies without quotes provided: training and education