Neerja Jain

The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care

BackgroundChronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progressionDesignCluster randomised controlled trial (CRT)MethodsThis three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education.The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD.A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention.Clinical Trials RegistrationISRCTN56023731. ClinicalTrials.gov identifier.

Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59–4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05–1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

HOW TO DEVELOP A PATIENT AND CARER ADVISORY GROUP IN A QUALITY IMPROVEMENT STUDY

BACKGROUND This paper explores how a group of people with renal or other vascular conditions collaborated with renal practitioners in undertaking a quality improvement project, the aim of which was to reduce variation in care for people with Stages 3-4 chronic kidney disease. DEVELOPMENT AND ROLE OF THE GROUP The patient advisory group supporting the project took a decisive and leading role in the creation of self-management materials and subsequent training for healthcare professionals and patients. The role of the patient advisory group was evaluated informally throughout the project. Confidence amongst the patient advisory group members grew as the project developed. CONCLUSION Clinicians are often unclear on how to involve patients and carers in quality improvement projects, yet it is increasingly recognised as important. In practice, patients with experience of long-term conditions can co-lead quality improvement projects. It is recommended that further evaluation of the role of advisory groups is warranted.

Increasing black, asian and minority ethnic (bame) patient & community awareness--using the peer educator model.

BACKGROUND Kidney Research UK, have been working since 2001 to raise health awareness, fund and oversee research into kidney related issues disproportionately affecting the BAME communities in the UK. Almost 10 years ago, the charity initiated its Peer Educator model which uses the natural skills of lay people and patients to raise awareness in these communities. AIMS This article will describe the work of the Charity in relation to patient and public engagement, describing the Peer Educator model and providing examples of how it has been used. It will then focus on the deployment and impact of Peer Educators in an end of life project that the charity was involved in. MATERIALS & METHODS Peer Educators (PEs) are ordinary people from the targeted community. In the case of our health improvement work, this has largely been the BAME communities. These people do not need any prior knowledge, training or experience in the subject matter. However, they do need to have a desire to give something back to their community in terms of health messages and also be passionate about the subject matter. They tend to have a natural empathy with the target groups in terms of culture, religion and language. RESULTS The Peer Educator model, is it has been found, to be a flexible and highly adaptable approach to addressing health issues in the BAME communities. It has been utilised by the charity to address everything from early disease detection, prevention, management, organ donation awareness, right through to end of life issues. The model has been well evaluated in the area of organ donation whereby its effectiveness has been proven. Moreover, there have been several notable outcomes from the end of life work including training and deployment of 10 Peer Educators who reached over 2,700 people from diverse South Asian communities, providing important information on who does what, when, and how to access it--in a culturally competent manner. DISCUSSION & CONCLUSION Kidney Research UKs Peer Educator initiative has been well established as an effective and flexible way to raise awareness and reach out to BAME patients and the communities at risk. The model has been deployed across the kidney disease spectrum including from early detection to diabetes management, right through to addressing organ donation and end of life issues.

RAISING AWARENESS OF CHRONIC KIDNEY DISEASE AMONG SOUTH ASIANS AND PRIMARY CARE: THE ABLE PROJECT

UNLABELLED Established renal failure as a complication of diabetes in 10 times greater in South Asians than in Caucasians. The objectives were: (1) to develop methods to increase community awareness and (2) to support general practices to improve chronic kidney disease (CKD) detection and management. The methods include: 1. Action research approach. 2. Public health education programme. 3. Audit in control and intervention practices. 4. Post-intervention focus group study determining changes in knowledge. 5. Evaluation and dissemination in community and primary care. RESULTS An evaluation of innovative resources and peer educator model demonstrated a positive feedback, increased knowledge and evidence of positive lifestyle change. Intervention with the practices has demonstrated the need to improve some aspects of CKD management. CONCLUSION This unique initiative has helped to identify practical strategies to address CKD awareness in these communities. However, the successful elements need to become part of mainstream National health Service and not just delivered by short-term projects.

A peer outreach initiative to increase the registration of minorities as organ donors

Background Black, Asian and minority ethnic (BAME) communities are disproportionately affected by inequalities in transplant services in the UK. There are some indications from pilot programmes that appeals for BAME organ donors may be more effectively communicated by employing grassroots, community-networking approaches, but such initiatives have not been adequately described or evaluated. Methods Lay individuals from BAME communities were trained as peer outreach workers. They attended a series of public events to promote knowledge of organ donation and transplantation among the public. Information was gathered from 806 evaluation forms completed by event attendees at 34 separate events. From these, 54 follow-up interviews were conducted with event attendees who completed evaluation forms, indicated that they intended to sign up to the NHS Organ Donor Register (ODR) within the next month and consented to follow-up. Results Peer outreach initiatives of the type evaluated are associated with increased numbers of BAME people registering as organ donors. A total of 8.8% of event attendees signed up to the NHS ODR. The programme was most effective with people who had previously considered becoming organ donors but who did not know how to go about it. It was less effective with people who had not previously considered it, or who were scared about signing up, or who feared family or religious disapproval. Conclusions Peer outreach programmes with BAME communities can be an effective way of reducing inequalities by increasing the number of people on the NHS ODR and encouraging people to think about the issue.