Understanding risk stratification of chronic kidney disease: qualitative study in primary care

Kristin Veighey; Emma Teasdale; Michelle Myall; Kate Henaghan-Sykes; Thomas Blakeman; Kinda Ibrahim; Bhargav Raut; Hazel Everitt; Simon D Fraser

doi:10.3399/BJGP.2025.0802

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CKD risk stratification: addressing hierarchy, multimorbidity, and alarm fatigue
Jingjing Jin, Jingjing Ding and Huiping Zhou

Published on: 27 April 2026

Published on: (27 April 2026)
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CKD risk stratification: addressing hierarchy, multimorbidity, and alarm fatigue
Jingjing Jin, Doctor, Zhejiang Chinese Medical University
Other Contributors:
Jingjing Ding, Doctor, Zhejiang Chinese Medical University

Huiping Zhou, Doctor, Zhejiang Chinese Medical University
Veighey and colleagues are to be congratulated for illuminating the barriers to chronic kidney disease (CKD) risk stratification in primary care.¹ Their application of normalisation process theory (NPT) provides a valuable framework, but we suggest additional methodological and clinical nuances must be considered.

Methodologically, blending GPs, nurses, and administrative staff into shared focus groups risks masking hierarchical power dynamics. In UK primary care, power imbalances between clinical partners and allied or administrative staff can lead to self-censorship. This may obscure genuine interprofessional frictions regarding workflow delegation, potentially skewing the understanding of collective action.²

Systemically, participants strongly advocated for automated IT coding and KFRE embedded scoring to facilitate risk stratification. However, introducing automated alerts without carefully assessing clinician cognitive load risks precipitating 'alarm fatigue'. If digital solutions are not strictly integrated with workflow, they risk becoming ignored pop-ups rather than effective decision aids.³

Finally, the time pressures highlighted by the authors should be viewed through the lens of multimorbidity. Many patients with CKD concurrently manage severe cardiovascular disease, diabetes, or frailty. A GP’s decision not to formally risk-stratify CKD may not solely reflect a lack of tool awareness,...
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Veighey and colleagues are to be congratulated for illuminating the barriers to chronic kidney disease (CKD) risk stratification in primary care.¹ Their application of normalisation process theory (NPT) provides a valuable framework, but we suggest additional methodological and clinical nuances must be considered.

Methodologically, blending GPs, nurses, and administrative staff into shared focus groups risks masking hierarchical power dynamics. In UK primary care, power imbalances between clinical partners and allied or administrative staff can lead to self-censorship. This may obscure genuine interprofessional frictions regarding workflow delegation, potentially skewing the understanding of collective action.²

Systemically, participants strongly advocated for automated IT coding and KFRE embedded scoring to facilitate risk stratification. However, introducing automated alerts without carefully assessing clinician cognitive load risks precipitating 'alarm fatigue'. If digital solutions are not strictly integrated with workflow, they risk becoming ignored pop-ups rather than effective decision aids.³

Finally, the time pressures highlighted by the authors should be viewed through the lens of multimorbidity. Many patients with CKD concurrently manage severe cardiovascular disease, diabetes, or frailty. A GP’s decision not to formally risk-stratify CKD may not solely reflect a lack of tool awareness, but rather a tacit 'disease prioritisation' within a constrained 10-minute consultation. Improving access to risk stratification is essential, but solutions should strengthen relational care and cognitive ergonomics, rather than simply adding automated alerts.

References
1. Veighey K, Teasdale E, Myall M, et al. Understanding risk stratification of chronic kidney disease: qualitative study in primary care. Br J Gen Pract. Apr 24 2026. DOI: 10.3399/BJGP.2025.0802.
2. Kitzinger J. Qualitative research. Introducing focus groups. BMJ, 1995;311(7000):299-302. DOI:10.1136/bmj.311.7000.299
3. Gani I, Litchfield I, Shukla D, Delanerolle G, Cockburn N, Pathmanathan A. Understanding "Alert Fatigue" in Primary Care: Qualitative Systematic Review of General Practitioners Attitudes and Experiences of Clinical Alerts, Prompts, and Reminders. J Med Internet Res, 2025;27:e62763. doi:10.2196/62763

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Competing Interests: None declared.