2.1| Study design and participant population
We conducted a qualitative descriptive study between 5/2019 and 10/2019 at three affiliated hospitals of Zhengzhou University. The three were public hospitals designated by local medical insurance department. We recruited two groups of respondents including a purposive sample of patients with advanced CKD and a convenience sample of nephrologists. The inclusion criteria for advanced CKD patients were 1) aged 18 or older; 2) eGFR<20 mL/min/1.73m2; 3) patient-initiated referral; 4) able to communication in Chinese; Exclusion criteria were :1) acute kidney injury; 2) be on regular dialysis; 3) inability to communicate (e.g. cognitive impairment); The inclusion for nephrologists were:1) provision medical services to patients with advanced CKD;2) at least 5 years of clinical experience;
Purposive sampling captured variation in age, self-referral number, CKD stage. All eligible participants invited to interview gave full informed consent. Sampling continued until data saturation, i.e. no new themes were identified in later interviews21.
Nephrologists were recruited via telephone or email by study coordinator (Shan, Y). Interested nephrologists agreed to participant this study. Another researcher (Gao, Y J) approached self-referral patients with advanced CKD after first staff-patients meeting about treatment decision. The recruitment strategy was adapted according to suggestion of clinical managers and clinic schedule. Study coordinator obtained all participants’ written inform consent and scheduled interviews. Face-to-face interviews were conducted at a private room and each interview lasted approximately 50 min.