Using chronic kidney disease trigger tools for safety and learning: a qualitative evaluation in East London primary care

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

BACKGROUND

CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes.

METHODS

We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work.

RESULTS

Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings.

CONCLUSIONS

This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.

PODCAST

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Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London

BACKGROUND

Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission.

AIM

To quantify the prevalence and identify the predictors of SABA overprescribing.

DESIGN AND SETTING

A cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs.

METHOD

Primary care medical record data for patients aged 5-80 years, with 'active' asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications.

RESULTS

In the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing.

CONCLUSION

In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4-12 a year could potentially save up to 70% of asthma admissions a year within that group.

Quality improvement at scale: evaluation of the drivers and barriers to adoption and sustainability of an intervention to reduce late referral in chronic kidney disease

This quality improvement project aimed to drive large scale and sustained change to reduce the burden of chronic kidney disease in the UK. The intervention is a software program that extracts relevant biochemical data from laboratory databases which then generate graphs of estimated kidney function (eGFR) over time. Graphs showing progressive kidney disease are sent directly back to general practitioners (GPs) to alert them to rereview patient care and if necessary, refer to renal services. The aim of this evaluation study was to explain the barriers and drivers to implementation and adoption of the eGFR graph intervention. This evaluation study involved 5 of the 20 participating renal units (sites). A developmental evaluation approach was used. Methods included collection of descriptive data about graph reporting; GP surveys (n=68); focus groups (n=4) with practices; face-to-face interviews with secondary care clinicians (n=10). Results showed the mean number of graphs reviewed per week per site was 230, taking 1 hour per week per site. Only 18.2% graphs highlighted a concerning decline in kidney function. Important enablers to sustain the intervention were low cost, easy to understand, a sense of local ownership and perceived impact. Barriers included nephrologists’ perceived increase in new referrals. We concluded that developmental evaluation can explain the barriers/drivers to implementation of a national quality improvement project that involves a variety of different stakeholders. The intervention has the potential to slow down progression of kidney disease due to the eGFR prompts alerting GPs to review the patient record and take action, such as reviewing medications and referring to renal teams if progressive kidney disease had not been identified previously.

Do virtual renal clinics improve access to kidney care? A preliminary impact evaluation of a virtual clinic in East London

Background

Early identification of people with CKD in primary care, particularly those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease.

The 2019 NHS Long Term Plan endorses the development of digitally-enabled services to replace the ‘unsustainable’ growth of the traditional out-patient model of care.Shared views of the complete health data available in the primary care electronic health record (EHR) can bridge the divide between primary and secondary care, and offers a practical solution to widen timely access to specialist advice.

Methods

We describe an innovative community kidney service based in the renal department at Barts Health NHS Trust and four local clinical commissioning groups (CCGs) in east London. An impact evaluation of the changes in service delivery used quantitative data from the virtual CKD clinic and from the primary care electronic health records (EHR) of 166 participating practices. Survey and interview data from health professionals were used to explore changes to working practices.

Results

Prior to the start of the service the general nephrology referral rate was 0.8/1000 GP registered population, this rose to 2.5/1000 registered patients by the second year of the service. The majority (> 80%) did not require a traditional outpatient appointment, but could be managed with written advice for the referring clinician. The wait for specialist advice fell from 64 to 6 days. General practitioners (GPs) had positive views of the service, valuing the rapid response to clinical questions and improved access for patients unable to travel to clinic. They also reported improved confidence in managing CKD, and high levels of patient satisfaction. Nephrologists valued seeing the entire primary care record but reported concerns about the volume of referrals and changes to working practices.

Conclusions

‘Virtual’ specialist services using shared access to the complete primary care EHR are feasible and can expand capacity to deliver timely advice. To use both specialist and generalist expertise efficiently these services require support from community interventions which engage primary care clinicians in a data driven programme of service improvement.