Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study

The Leicester, Leicestershire and Rutland quality improvement project and integrated chronic kidney disease system: implementation within a primary care network

BACKGROUND

The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. This paper presents a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme.

METHOD

Patients are optimised to guidelines from the National Institute for Health and Care Excellence, by a primary care clinical team who are supported by nephrology consultants and nephrology pharmacists. Multidisciplinary team meetings take place with secondary care specialists and primary care staff. Learning is passed to the community clinicians for better patient treatment locally.

RESULTS

A total of 526 patients were reviewed under this project.The total number of referrals to secondary care which were discharged following first outpatient appointment, reduced from 42.9% to 10%. This reduction of 32.9% represents the optimisation of patient cases through this quality improvement project. Patients can be optimised and managed within the community, reducing the number of unnecessary referrals to secondary care.

CONCLUSION

This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base. Medicine management and the use of clinical staff are optimised in both primary and secondary care.

Making treatment guideline recommendations in chronic kidney disease and type 2 diabetes more accessible to primary care providers in the United States

Clinical practice guidelines for the management of chronic kidney disease (CKD) associated with type 2 diabetes (T2D) are designed to assist healthcare professionals with clinical decision making by providing recommendations on the screening, detection, management, and treatment of these conditions. However, primary care practitioners (PCPs) may have clinical inertia when it comes to routinely enacting CKD and T2D guideline recommendations in their clinical practices. Guideline developers have published a range of resources with the aim of facilitating easier access to guideline recommendations to support efficient and consistent implementation into clinical practice of PCPs. Challenges remain in providing strategies to reduce inertia in the application of guideline recommendations in primary care. In this review, we explore reasons behind the low level of awareness and poor uptake of published evidence-based care approaches to the optimal management of patients with T2D and CKD. Finally, we present suggestions on strategies to improve the implementation of guideline-directed recommendations in primary care.

Understanding Hospital Readmissions: Insights, Patterns, and Interventions for Improvement in Chronic Kidney Disease

BACKGROUND

Hospital readmissions among chronic kidney disease (CKD) patients pose substantial challenges in healthcare, impacting both patients and healthcare systems. Understanding the patterns and determinants of CKD-related readmissions is crucial for devising effective interventions.

OBJECTIVE

This research aimed to investigate the factors contributing to hospital readmissions among CKD patients, identify the primary reasons for readmissions, and explore potential interventions to mitigate readmission risks.

METHODS

A retrospective analysis was conducted among a cohort of 300 CKD patients over an 18-month period at a tertiary care unit specializing in nephrology services. Data on demographics, CKD stages, comorbidities, reasons for readmissions, and lengths of hospital stays were analyzed. Logistic regression models were employed to identify predictors of readmissions.

RESULTS

Advancing CKD stages were associated with increased readmission rates, with higher rates observed in older patients. Cardiovascular complications and acute kidney injury were prominent reasons for readmissions. Age, comorbid conditions, and previous hospitalizations emerged as significant predictors of readmissions. Lengths of hospital stays during readmissions were also correlated with CKD stages.

CONCLUSION

The research underscores the complex interplay of demographic and clinical factors contributing to hospital readmissions among CKD patients. Tailored interventions addressing disease severity, comorbidities, and patient-specific characteristics are pivotal in reducing readmission risks and enhancing care outcomes for this population.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

The use of theory in process evaluations conducted alongside randomized trials of implementation interventions: A systematic review

Interventions to implement changes into health care practice (i.e., implementation interventions) are critical to improving care but their effects are poorly understood. Two strategies to better understand intervention effects are conducting process evaluations and using theoretical approaches (i.e., theories, models, frameworks). The extent to which theoretical approaches have been used in process evaluations conducted alongside trials of implementation interventions is unclear. In this study context, we reviewed (a) the proportion of process evaluations citing theoretical approaches, (b) which theoretical approaches were cited, and (c) whether and how theories were used. Systematic review (PROSPERO: CRD42016042789). MEDLINE, PsycINFO, Embase, CINAHL, and Cochrane CENTRAL were searched up to July 31, 2017. For all studies, data extraction included names and types of theoretical approaches cited. For studies citing a theory, data extraction included study characteristics and extent of theory use (i.e., "informed by," "applied," "tested," "built/created" theory). We identified 123 process evaluations. Key findings: (a) 77 (63%) process evaluations cited a theoretical approach; (b) the most cited theory was normalization process theory; (c) 32 (26%) process evaluations used theory: 7 (22%) were informed by, 18 (56%) applied, 7 (22%) tested, and none built/created theory. Although nearly two thirds of process evaluations cited a theoretical approach, only a quarter were informed by, applied, or tested a theory-despite the potential complementarity of these strategies. When theory was used, it was primarily applied. Using theory more substantively in process evaluations may accelerate our understanding of how implementation interventions operate.

Future Health Today: codesign of an electronic chronic disease quality improvement tool for use in general practice using a service design approach

OBJECTIVE

To codesign an electronic chronic disease quality improvement tool for use in general practice.

DESIGN

Service design employing codesign strategies.

SETTING

General practice.

PARTICIPANTS

Seventeen staff (general practitioners, nurses and practice managers) from general practice in metropolitan Melbourne and regional Victoria and five patients from metropolitan Melbourne.

INTERVENTIONS

Codesign sessions with general practice staff, using a service design approach, were conducted to explore key design criteria and functionality of the audit and feedback and clinical decision support tools. Think aloud interviews were conducted in which participants articulated their thoughts of the resulting Future Health Today (FHT) prototype as they used it. One codesign session was held with patients. Using inductive and deductive coding, content and thematic analyses explored the development of a new technological platform and factors influencing implementation of the platform.

RESULTS

Participants identified that the prototype needed to work within their existing workflow to facilitate automated patient recall and track patients with or at-risk of specific conditions. It needed to be simple, provide visual snapshots of information and easy access to relevant guidelines and facilitate quality improvement activities. Successful implementation may be supported by: accuracy of the algorithms in FHT and data held in the practice; the platform supporting planned and spontaneous interactions with patients; the ability to hide tools; links to Medicare Benefits Schedule; and prefilled management plans. Participating patients supported the use of the platform in general practice. They suggested that use of the platform demonstrates a high level of patient care and could increase patient confidence in health practitioners.

CONCLUSION

Study participants worked together to design a platform that is clear, simple, accurate and useful and that sits within any given general practice setting. The resulting FHT platform is currently being piloted in general practices and will continue to be refined based on user feedback.

Normalizing inconvenience to promote childhood vaccination: a qualitative implementation evaluation of a novel Michigan program

Background

In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability.

Methods

We conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring).

Results

There was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring).

Conclusions

The immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.

Factors associated with chronic kidney disease: epidemiological survey of the National Health Survey

OBJECTIVE

To identify the prevalence of chronic kidney disease (CKD) self-reported in Brazil and characterize the factors associated with it.

METHODS

This study was a cross-sectional health survey with a household-based, the National Health Survey, performed in 2013. The outcome in the present study was the prevalence of CKD. The groups of explanatory variables were socio-demographic characteristics, lifestyles, chronic self-reported diseases, anthropometry, and health evaluation. The prevalence of CKD, e their 95% respective confidence interval were estimated, univariate analysis and the multiple logistic regression model were calculated, and remained the variables statistically significant (p < 0.05).

RESULTS

It noticed that 1.42% (95%CI 1.33 - 1.52) of the 60,202 interviewees self-reported CKD. The OR increased progressively with age, being 2.68 among the elderly with 65 years or more (95%CI 1.75 - 4.09). Having health plans with OR = 1.51 (95%CI 1.28 - 1.78), as well as smoking, hypertension and high cholesterol and poor self-reported health with OR = 1.75 (95%CI 1.45 - 2.12), OR = 1.20 (95%CI 1.02 - 1.42), OR = 1.83 (95%CI 1.56 - 2.15), OR = 4.70 (95%CI 3.75 - 5.88), respectively, showed a higher chance of CKD.

CONCLUSIONS

The associated variables were increasing age, health plan coverage, smoking, hypertension, hypercholesterolemia, and regular or poor health status. The knowledge of CKD prevalence in Brazil and risk and protection factors are essential for disease prevention and the establishment of supporting public health policies.

Who do we discharge from renal clinic and what does it mean for primary care?

BACKGROUND

It is unclear whether discharging patients from renal clinic to primary care is safe.

AIM

To determine the characteristics, primary care monitoring and renal outcomes of patients discharged from renal clinic.

DESIGN AND SETTING

A retrospective study of 2236 adults discharged from a tertiary renal clinic between 2013-2018.

METHOD

Patient demographics, primary renal disease, laboratory results and timeline dates were collected from the renal IT system. Timing of blood tests, renal progression, needing dialysis and patient survival were analysed. Reasons for discharge and cause of disease progression were reviewed in patients developing new estimated glomerular filtration rate <20 ml/min/1.73 m2.

RESULTS

Patients were older (median age 75; interquartile range 63-84) with non-progressive, seemingly non-proteinuric renal disease. Median time to repeat blood test post-discharge was 75 days with 90% tested within 12 months. Sixty-six percent saw an improvement in kidney function post-discharge and only 13% had a decline of >10 ml/min/1.73 m2. Only 132 patients (6%) developed new advanced chronic kidney disease (estimated glomerular filtration rate < 20 ml/min/1.73 m2) of whom 40% were palliative, 36% had developed acute kidney injury and 23% discharged for failing to attend clinic. One hundred and thirty-four patients (6%) were referred back to nephrology and eight started dialysis of whom six were discharged for failure to attend clinic.

CONCLUSION

Most discharged patients are low risk of progressive renal disease and need infrequent monitoring. Non-adherent patients discharged for failing to attend appear to be at risk of poor outcomes and new strategies are needed to better support this population.

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

Background

Chronic kidney disease (CKD) is growing population health concern worldwide, and with early identification and effective management, kidney disease progression can be slowed or prevented. Most patients with risk factors for chronic kidney disease are treated within primary healthcare. Therefore, it is important to understand how best to support primary care providers (PC-P) to detect and manage chronic kidney disease. The aim of this systematic review was to evaluate barriers and enablers to the diagnosis and management of CKD in primary care.

Methods

A systematic review of qualitative research on the barriers and/or enablers to detection and/or management of CKD in adults within primary healthcare was conducted. The databases Medline (EBSCO), PubMed, Cochrane CENTRAL, CINAHL (EBSCO) and Joanna Briggs Institute Evidence Based Practice (Ovid) were searched until 27th August 2019. Barriers and/or enablers reported in each study were identified, classified into themes, and categorised according to the Theoretical Domains Framework.

Results

A total of 20 studies were included in this review. The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the ‘Environmental context and resources’ domain (n = 16 studies). Overall, the most common barrier identified was a lack of time (n = 13 studies), followed by a fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines (both n = 10 studies). Overall, the most common enabler identified was the presence of supportive technology to identify and manage CKD (n = 7 studies), followed by the presence of a collaborative relationship between members of the healthcare team (n = 5 studies).

Conclusion

This systematic review identified a number of barriers and enablers which PC-P face when identifying and managing CKD. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently co-morbid nature of CKD. Enhanced collaboration between PC-P and nephrology services may also support PC-Ps when diagnosing CKD in primary care, and facilitate improved patient self-management.

Fatores associados à doença renal crônica segundo critérios laboratoriais da Pesquisa Nacional de Saúde

RESUMO: Objetivo: Identificar a prevalência da taxa de filtração glomerular estimada pelo clearance da creatinina endógena (estimativa da taxa de filtração glomerular - eTFG) menor que 60 mL/min/1,73 m2 no Brasil e os fatores associados. Métodos: Trata-se de um inquérito epidemiológico transversal de base domiciliar. Os dados foram obtidos em subamostra de participantes da Pesquisa Nacional de Saúde (PNS), realizada em 2013, na qual foi feita coleta de sangue para medida de creatinina plasmática e calculado a eTFG (n = 7.457). Os grupos de variáveis explicativas foram: características sociodemográficas, estilos de vida, doenças crônicas, antropometria e avaliação de saúde. Foram estimadas as prevalências de eTFG < 60 mL/min/1,73 m2 e os respectivos intervalos de confiança de 95% (IC95%) utilizando a regressão de Poisson para calcular a razão de prevalência bruta (RPb) e ajustada (RPaj) por idade, sexo, escolaridade e região. Resultados: A prevalência de eTFG < 60 mL/min/1,73 m2 foi de 6,48% (IC95% 5,88 - 7,09). Após ajuste, mantiveram-se associados: sexo feminino (RP = 1,40; IC95% 1,16 - 1,68), idade 45-59 anos (RPaj = 7,27; IC95% 3,8 - 14,1), 60 anos ou mais (RPaj = 33,55; IC95% 17,8 - 63,4), obesidade (RP = 1,32; IC95% 1,1 - 1,7), diabetes (RP = 1,44; IC95% 1,2 - 1,8), autoavaliação de saúde ruim/muito ruim (RP = 1,50; IC95% 1,2 - 1,9); menor RPaj foi encontrado nas regiões Nordeste e Sudeste, entre fumantes e com consumo elevado de sal. Conclusão: eTFG < 60 mL/min/1,73 m2 foi mais elevada no sexo feminino, aumentou com a idade, foi associada com obesidade, diabetes e pior avaliação de saúde. O conhecimento da prevalência da doença renal crônica, por meio de exames bioquímicos e dos fatores de risco e proteção, é essencial para subsidiar políticas públicas de saúde.

Awareness and Discussions About Chronic Kidney Disease Among African-Americans with Chronic Kidney Disease and Hypertension: a Mixed Methods Study

BACKGROUND

Routine primary care visits provide an educational opportunity for African-Americans with chronic kidney disease (CKD) and CKD risk factors such as hypertension. The nature of patient-physician discussions about CKD and their impact on CKD awareness in this population have not been well explored.

OBJECTIVE

To characterize patient CKD awareness and discussions about CKD between patients and primary care physicians (PCPs).

DESIGN

Mixed methods study.

PATIENTS

African-American patients with uncontrolled hypertension (≥ 140/90 mmHg) and CKD (albuminuria or eGFR < 60 ml/min/1.73 m2) recruited from an urban primary care clinic.

MAIN MEASURES

We assessed patient CKD awareness with questionnaires and audio-recorded patients-PCP discussions during a routine visit. We characterized discussions and used multivariate regression analysis to identify independent patient and visit predictors of CKD awareness or CKD discussions.

RESULTS

Among 48 African-American patients with uncontrolled hypertension and CKD, 29% were aware of their CKD. After adjustment, CKD awareness was associated with moderate-severe CKD (stages 3-4) (vs. mild CKD [stages 1-2]) (prevalence ratio [PR] 2.82; 95% CI 1.18-6.78) and inversely associated with diabetes (vs. without diabetes) (PR 0.28; 95% CI 0.10-0.75). CKD discussions occurred in 30 (63%) visits; most focused on laboratory assessment (n = 23, 77%) or risk factor management to delay CKD progression (n = 19, 63%). CKD discussions were associated with moderate-severe CKD (vs. mild CKD) (PR 1.57; 95% CI 1.04-2.36) and diabetes (vs. without diabetes) (PR 1.42; 95% CI 1.09-1.85), and inversely associated with uncontrolled hypertension (vs. controlled) (PR 0.58; 95% CI 0.92-0.89). In subgroup analysis, follow-up CKD awareness did not change by presence or absence of CKD discussion (10.5% vs. 7.7%, p = 0.8).

CONCLUSIONS

In patients at risk of CKD progression, few were aware of CKD, and CKD discussions were not associated with CKD awareness. More resources may be needed to enhance the clarity of clinical messages regarding CKD and its significance for patients' health.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01902719.

Trends in Quality of Care for Patients with CKD in the United States

BACKGROUND AND OBJECTIVES

Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a national, serial, cross-sectional study of visits to office-based ambulatory care practices for adults with diagnosed CKD from the years 2006 to 2014. We assessed the following quality indicators: (1) BP measurement, (2) uncontrolled hypertension, (3) uncontrolled diabetes, (4) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use among patients with hypertension, (5) statin use if age ≥50 years old, and (6) nonsteroidal anti-inflammatory drug use. Using multivariable linear regression and chi-squared analysis, we examined the change in quality performance over time.

RESULTS

Between 2006 and 2014, there were 7099 unweighted visits for patients with CKD representing 186,961,565 weighted visits. There was no difference in the prevalence of uncontrolled hypertension (>130/80 mm Hg) over time (46% in 2006-2008 versus 48% in 2012-2014; P=0.50). There was a high prevalence of uncontrolled diabetes in 2012-2014 (40% for hemoglobin A1c >7%). The prevalence of ACEi/ARB use decreased from 45% in 2006-2008 to 36% in 2012-2014, which did not reach statistical significance (P=0.07). Statin use in patients with CKD who were 50 years or older was low and remained unchanged from 29% in 2006-2008 to 31% in 2012-2014 (P=0.92).

CONCLUSIONS

In a nationally representative dataset, we found that patients with CKD had a high prevalence of uncontrolled hypertension and diabetes and a low use of statins that did not improve over time and was not concordant with guidelines.

Process evaluations of primary care interventions addressing chronic disease: a systematic review

OBJECTIVE

Process evaluations (PEs) alongside randomised controlled trials of complex interventions are valuable because they address questions of for whom, how and why interventions had an impact. We synthesised the methods used in PEs of primary care interventions, and their main findings on implementation barriers and facilitators.

DESIGN

Systematic review using the UK Medical Research Council guidance for PE as a guide.

DATA SOURCES

Academic databases (MEDLINE, SCOPUS, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Global Health) were searched from 1998 until June 2018.

ELIGIBILITY CRITERIA

We included PE alongside randomised controlled trials of primary care interventions which aimed to improve outcomes for patients with non-communicable diseases.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened and conducted the data extraction and synthesis, with a third reviewer checking a sample for quality assurance.

RESULTS

69 studies were included. There was an overall lack of consistency in how PEs were conducted and reported. The main weakness is that only 30 studies were underpinned by a clear intervention theory often facilitated by the use of existing theoretical frameworks. The main strengths were robust sampling strategies, and the triangulation of qualitative and quantitative data to understand an intervention's mechanisms. Findings were synthesised into three key themes: (1) a fundamental mismatch between what the intervention was designed to achieve and local needs; (2) the required roles and responsibilities of key actors were often not clearly understood; and (3) the health system context-factors such as governance, financing structures and workforce-if unanticipated could adversely impact implementation.

CONCLUSION

Greater consistency is needed in the reporting and the methods of PEs, in particular greater use of theoretical frameworks to inform intervention theory. More emphasis on formative research in designing interventions is needed to align the intervention with the needs of local stakeholders, and to minimise unanticipated consequences due to context-specific barriers.

PROSPERO REGISTRATION NUMBER

CRD42016035572.

Mechanism of Action and Clinical Attributes of Auryxia® (Ferric Citrate)

Chronic kidney disease (CKD) is a major cause of morbidity and premature mortality and represents a significant global public health issue. Underlying this burden are the many complications of CKD, including mineral and bone disorders, anemia, and accelerated cardiovascular disease. Hyperphosphatemia and elevated levels of fibroblast growth factor 23 (FGF23) have been identified as key independent risk factors for the adverse cardiovascular outcomes that frequently occur in patients with CKD. Auryxia® (ferric citrate; Keryx Biopharmaceuticals, Inc., Boston, MA, USA) is an iron-based compound with distinctive chemical characteristics and a mechanism of action that render it dually effective as a therapy in patients with CKD; it has been approved as a phosphate binder for the control of serum phosphate levels in adult CKD patients treated with dialysis and as an iron replacement product for the treatment of iron deficiency anemia in adult CKD patients not treated with dialysis. This review focuses on Auryxia, its mechanism of action, and the clinical attributes that differentiate it from other, non-pharmaceutical-grade, commercially available forms of ferric citrate and from other commonly used phosphate binder and iron supplement therapies for patients with CKD. Consistent with the chemistry and mechanism of action of Auryxia, multiple clinical studies have demonstrated its efficacy in both lowering serum phosphate levels and improving iron parameters in patients with CKD. Levels of FGF23 decrease significantly with Auryxia treatment, but the effects associated with the cardiovascular system remain to be evaluated in longer-term studies.

Primary care provider perceptions of enablers and barriers to following guideline-recommended laboratory tests to confirm chronic kidney disease: a qualitative descriptive study

Background

Patients should receive follow-up serum creatinine tests after an initial abnormal result to diagnose chronic kidney disease. However, half of the time this fails to occur in primary care. We interviewed primary care providers to better understand their perceptions of enablers and barriers to following this guideline-recommended care.

Methods

We performed a qualitative descriptive study guided by the Theoretical Domains Framework (TDF), a framework for behavioural change. We used purposeful sampling to recruit primary care providers (physicians and nurse practitioners) based on provider and practice characteristics (rural, solo versus team practice, etc.) from Ontario, Canada. We completed one-on-one interviews with providers using a semi-structured and open-ended interview guide based on the 14 TDF domains. We alternated between data collection and analysis, where we used directed content analysis to identify frequent, important, and conflicting enablers and barriers.

Results

We completed 13 interviews with nine primary care physicians and four nurse practitioners. Nine themes related to the TDF emerged from the data: 1) environmental context and resources, 2) knowledge, 3) memory, attention, and decision processes, 4) beliefs about consequences, 5) goals, 6) social or professional role, 7) behavioural regulation, 8) skills, and 9) optimism. Within these themes, we identified 16 enablers and five barriers. Some enablers included, providers’ knowledge on appropriate testing, their motivation to order these tests, and their use of tools and resources to help order follow-up serum creatinine tests. However, providers perceived some barriers including that ordering confirmatory laboratory tests for chronic kidney disease was not always a priority in regards to other care they wish to provide. Providers also noted that a perceived barrier is patients not going to the laboratory to complete the test.

Conclusions

We identified novel enablers and barriers to primary care providers completing guideline recommended repeat testing for the diagnosis of chronic kidney disease. Similar research is needed to understand the views of patients. These research findings can be used to inform strategies to improve the quality of care.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0879-2) contains supplementary material, which is available to authorized users.

General practitioners' views on managing knee osteoarthritis: a thematic analysis of factors influencing clinical practice guideline implementation in primary care

Background

Osteoarthritis (OA) is diagnosed and managed primarily by general practitioners (GPs). OA guidelines recommend using clinical criteria, without x-ray, for diagnosis, and advising strengthening exercise, aerobic activity and, if appropriate, weight loss as first-line treatments. These recommendations are often not implemented by GPs. To facilitate GP uptake of guidelines, greater understanding of GP practice behaviour is required. This qualitative study identified key factors influencing implementation of these recommendations in the primary-care setting.

Methods

Semi-structured interviews with eleven GPs were conducted, transcribed verbatim, coded by two independent researchers and analysed with an interpretive thematic approach using the COM-B model (Capability/Opportunity/Motivation-Behaviour) as a framework.

Results

Eleven themes were identified. Psychological capability themes: knowledge gaps, confidence to effectively manage OA, and skills to facilitate lifestyle change. Physical opportunity themes: system-related factors including time limitations, and patient resources. Social opportunity theme: influences from patients. Reflective motivation themes: GP's perceived role, and assumptions about people with knee OA. Automatic motivation themes: optimism, habit, and unease discussing weight. The findings demonstrated diverse and interacting influences on GPs' practice.

Conclusion

The identified themes provide insight into potential interventions to improve OA management in primary-care settings. Key suggestions include: improvements to OA clinical guidelines; targeting GP education to focus on identified knowledge gaps, confidence, and communication skills; development and implementation of new models of service delivery; and utilising positive social influences to facilitate best-practice behaviours. Complex, multimodal interventions that address multiple factors (both barriers and facilitators) are likely to be necessary.

Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review

BACKGROUND

Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes.

METHODS

A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively.

RESULTS

Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus.

CONCLUSIONS

This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.

General practitioners' perspectives on management of early-stage chronic kidney disease: a focus group study

BACKGROUND

Guideline adherence in chronic kidney disease management is low, despite guideline implementation initiatives. Knowing general practitioners' (GPs') perspectives of management of early-stage chronic kidney disease (CKD) and the applicability of the national interdisciplinary guideline could support strategies to improve quality of care.

METHOD

Qualitative focus group study with 27 GPs in the Netherlands. Three analysts open-coded and comparatively analysed the data. Mind-mapping sessions were performed after data-saturation.

RESULTS

Five themes emerged: defining CKD, knowledge and awareness, patient-physician interaction, organisation of CKD care and value of the guideline. A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. Striving to inform well enough without creating anxiety and to explain suitably for the intellectual ability of the patient caused tension in the patient-physician interaction. Integration with cardiovascular disease-management programmes was mentioned as a way of implementing CKD care in the future. The guideline was perceived as a rough guide rather than a leading document.

CONCLUSION

CKD is perceived as an abstract rather than a clinical concept. Abstractness plays a role in all formulated themes. Management of CKD patients in primary care is complex and is influenced by physician-bound considerations related to individual knowledge and perception of the importance of CKD. Strategies are needed to improve GPs' understanding of the concept of CKD by education, a holistic approach to guidelines, and integration of CKD care into cardiovascular programmes.

TRIAL REGISTRATION

Not applicable.

User Requirements for a Chronic Kidney Disease Clinical Decision Support Tool to Promote Timely Referral

BACKGROUND

Timely referral of patients with CKD has been associated with cost and mortality benefits, but referrals are often done too late in the course of the disease. Clinical decision support (CDS) offers a potential solution, but interventions have failed because they were not designed to support the physician workflow. We sought to identify user requirements for a chronic kidney disease (CKD) CDS system to promote timely referral.

METHODS

We interviewed primary care physicians (PCPs) to identify data needs for a CKD CDS system that would encourage timely referral and also gathered information about workflow to assess risk factors for progression of CKD. Interviewees were general internists recruited from a network of 14 primary care clinics affiliated with Brigham and Women's Hospital (BWH). We then performed a qualitative analysis to identify user requirements and system attributes for a CKD CDS system.

RESULTS

Of the 12 participants, 25% were women, the mean age was 53 (range 37-82), mean years in clinical practice was 27 (range 11-58). We identified 21 user requirements. Seven of these user requirements were related to support for the referral process workflow, including access to pertinent information and support for longitudinal co-management. Six user requirements were relevant to PCP management of CKD, including management of risk factors for progression, interpretation of biomarkers of CKD severity, and diagnosis of the cause of CKD. Finally, eight user requirements addressed user-centered design of CDS, including the need for actionable information, links to guidelines and reference materials, and visualization of trends.

CONCLUSION

These 21 user requirements can be used to design an intuitive and usable CDS system with the attributes necessary to promote timely referral.

Use of theory to plan or evaluate guideline implementation among physicians: a scoping review

BACKGROUND

Guidelines support health care decision-making and high quality care and outcomes. However, their implementation is sub-optimal. Theory-informed, tailored implementation is associated with guideline use. Few guideline implementation studies published up to 1998 employed theory. This study aimed to describe if and how theory is now used to plan or evaluate guideline implementation among physicians.

METHODS

A scoping review was conducted. MEDLINE, EMBASE, and The Cochrane Library were searched from 2006 to April 2016. English language studies that planned or evaluated guideline implementation targeted to physicians based on explicitly named theory were eligible. Screening and data extraction were done in duplicate. Study characteristics and details about theory use were analyzed.

RESULTS

A total of 1244 published reports were identified, 891 were unique, and 716 were excluded based on title and abstract. Among 175 full-text articles, 89 planned or evaluated guideline implementation targeted to physicians; 42 (47.2%) were based on theory and included. The number of studies using theory increased yearly and represented a wide array of countries, guideline topics and types of physicians. The Theory of Planned Behavior (38.1%) and the Theoretical Domains Framework (23.8%) were used most frequently. Many studies rationalized choice of theory (83.3%), most often by stating that the theory described implementation or its determinants, but most failed to explicitly link barriers with theoretical constructs. The majority of studies used theory to inform surveys or interviews that identified barriers of guideline use as a preliminary step in implementation planning (76.2%). All studies that evaluated interventions reported positive impact on reported physician or patient outcomes.

CONCLUSIONS

While the use of theory to design or evaluate interventions appears to be increasing over time, this review found that one half of guideline implementation studies were based on theory and many of those provided scant details about how theory was used. This limits interpretation and replication of those interventions, and seems to result in multifaceted interventions, which may not be feasible outside of scientific investigation. Further research is needed to better understand how to employ theory in guideline implementation planning or evaluation.

Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach

BACKGROUND

The detection and management of chronic kidney disease lies within primary care; however, performance measures applicable in the Canadian context are lacking. We sought to develop a set of primary care quality indicators for chronic kidney disease in the Canadian setting and to assess the current state of the disease's detection and management in primary care.

METHODS

We used a modified Delphi panel approach, involving 20 panel members from across Canada (10 family physicians, 7 nephrologists, 1 patient, 1 primary care nurse and 1 pharmacist). Indicators identified from peer-reviewed and grey literature sources were subjected to 3 rounds of voting to develop a set of quality indicators for the detection and management of chronic kidney disease in the primary care setting. The final indicators were applied to primary care electronic medical records in the Electronic Medical Record Administrative data Linked Database (EMRALD) to assess the current state of primary care detection and management of chronic kidney disease in Ontario.

RESULTS

Seventeen indicators made up the final list, with 1 under the category Prevalence, Incidence and Mortality; 4 under Screening, Diagnosis and Risk Factors; 11 under Management; and 1 under Referral to a Specialist. In a sample of 139 993 adult patients not on dialysis, 6848 (4.9%) had stage 3 or higher chronic kidney disease, with the average age of patients being 76.1 years (standard deviation [SD] 11.0); 62.9% of patients were female. Diagnosis and screening for chronic kidney disease were poorly performed. Only 27.1% of patients with stage 3 or higher disease had their diagnosis documented in their cumulative patient profile. Albumin-creatinine ratio testing was only performed for 16.3% of patients with a low estimated glomerular filtration rate (eGFR) and for 28.5% of patients with risk factors for chronic kidney disease. Family physicians performed relatively better with the management of chronic kidney disease, with 90.4% of patients with stage 3 or higher disease having an eGFR performed in the previous 18 months and 83.1% having a blood pressure recorded in the previous 9 months.

INTERPRETATION

We propose a set of measurable indicators to evaluate the quality of the management of chronic kidney disease in primary care. These indicators may be used to identify opportunities to improve current practice in Canada.

Impact of Delay in Diagnosis in Outcomes in MEN1: Results From the Dutch MEN1 Study Group

OBJECTIVE

Identifying a germline mutation in the multiple endocrine neoplasia type 1 (MEN1) gene in an index case has consequences for a whole family. Eligible family members should be offered genetic counseling and MEN1 mutation testing. Subsequently, clinical screening of mutation carriers according to the guidelines should be initiated. We assessed whether there is a lag time from MEN1 diagnosis of the index case to MEN1 diagnosis of family members. In addition, we determined whether this lag time was associated with an increased morbidity and mortality risk.

DESIGN

A cohort study was performed using the Dutch MEN1 database, including >90% of the Dutch MEN1 population >16 years of age (n = 393).

RESULTS

Fifty-eight MEN1 families were identified, of whom 57 were index cases and 247 were non-index cases (n = 304). The median lag time in MEN1 diagnosis of family members was 3.5 (range, 0-30) years. At the time of MEN1 diagnosis, 30 (12.1%) non-index cases had a duodenopancreatic neuroendocrine tumor, of whom 20% had metastases with a mean lag time of 10.9 years, in comparison with 7.1 years without metastases. Twenty-five (10.1%) non-index cases had a pituitary tumor, of whom 80% had a microadenoma and 20% had a macroadenoma, with mean lag times of 7.2 and 10.6 years, respectively. Ninety-five (38.4%) non-index cases had a primary hyperparathyroidism with a mean lag time of 9.5 years in comparison with seven patients without a primary hyperparathyroidism with a mean lag time of 3 years (P = .005). Ten non-index cases died because of a MEN1-related cause that developed during or before the lag time.

CONCLUSION

There is a clinically relevant delay in MEN1 diagnosis in families because of a lag time between the diagnosis of an index case and the rest of the family. More emphasis should be placed on the conduct of proper counseling and genetic testing in all eligible family members.