Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care : a qualitative study

Funding This article presents independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR) (reference:120). JE was also supported by the NIHR Programme Grants for Applied Research programme (Reference: RP-PG-1210-12012). DSL and LL are supported by the NIHR Oxford Biomedical Research CentrePeer reviewedPublisher PD

Understanding the implementation of interventions to improve the management of chronic kidney disease in primary care: a rapid realist review

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Experiences of care planning in England: interviews with patients with long term conditions.

BACKGROUND: The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England. METHODS: We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes. RESULTS: No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term 'care planning'. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term "reactive" care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described. CONCLUSIONS: Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

The challenge of ageing populations and patient frailty: can primary care adapt?

Health care systems worldwide are having to adapt to ageing populations and increasing numbers of older people with frailty with complex health and social needs, and in the UK primary care is at the frontline of policy attempts to meet this challenge, but achieving the goal of making frailty an integral part of primary care practice is not without considerable challenge

Identification and management of frailty in english primary care: a qualitative study of national policy

Background: Policymakers are directing attention to addressing the needs of an ageing population. Since 2017, general practices in England have been contractually required to identify and code ‘frailty’ as a new clinical concept and, in doing so, support targeted management for this population with the aim of improving outcomes. However, embedding frailty policies into routine practice is not without challenges and little is currently known about the success of the programme. Aim: To explore the implementation of a national policy on frailty identification and management in English primary care. Design & setting; Qualitative study entailing interviews with primary care professionals in the North of England. Method: Semi-structured interviews were conducted with GPs (n = 10), nurses (n = 6), practice managers (n = 3), and health advisors (n = 3). Normalisation process theory (NPT) and ‘system thinking’ provided sensitising frameworks to support data collection and analysis. Results: Primary care professionals were starting to use the concept of frailty to structure care within practices and across organisations; however, there was widespread concern about the challenge of providing expanded care for the identified needs with existing resources. Concerns were also expressed around how best to identify the frail subpopulation and the limitations of current tools for this, and there was a professional reticence to use the term ‘frailty’ with patients. Conclusion: Findings suggests that additional, focused resources and the development of a stronger evidence base are essential to facilitate professional engagement in policies to improve the targeted coding and management of frailty in primary care

Dismembering organisation: The coordination of algorithmic work in healthcare

Algorithms are increasingly being adopted in healthcare settings, promising increased safety, productivity and efficiency. The growing sociological literature on algorithms in healthcare shares an assumption that algorithms are introduced to ‘support’ decisions within an interactive order that is predominantly human-oriented. We present a different argument, calling attention to the manner in which organisations can end up introducing a non-negotiable disjuncture between human initiated care work and work that supports algorithms, which we call algorithmic work. Drawing on an ethnographic study, we describe how two hospitals in England implemented an Acute Kidney Injury (AKI) algorithm and we analyse ‘interruptions’ to the algorithm’s expected performance. When the coordination of algorithmic work occludes care work, we find a ‘dismembered’ organisation that is algorithmically-oriented rather than human-oriented. In our discussion, we examine the consequences of coordinating human and non-human work in each hospital and conclude by urging sociologists of organisation to attend to the importance of the formal in algorithmic work. As the use of algorithms becomes widespread, our analysis provides insight into how organisations outside of healthcare can also end up severing tasks from human experience when algorithmic automation is introduced

Post-discharge care following acute kidney injury: quality improvement in primary care

BACKGROUND: Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI. DESIGN: We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI. RESULTS: AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality. CONCLUSION: The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI

Implementation of clinical decision support to manage acute kidney injury in secondary care: an ethnographic study

Background: Over the past decade, acute kidney injury (AKI) has become a global priority for improving patient safety and health outcomes. In the UK, a confidential inquiry into AKI led to the publication of clinical guidance and a range of policy initiatives. National patient safety directives have focused on the mandatory establishment of clinical decision support systems (CDSSs) within all acute National Health Service (NHS) trusts to improve the detection, alerting and response to AKI. We studied the organisational work of implementing the AKI CDSSs within routine hospital care. Methods: An ethnographic study comprising non-participant observation and interviews was conducted in two NHS hospitals, delivering AKI quality improvement programmes, located in one region of England. Three researchers conducted a total of 49 interviews and 150 hours of observation over an 18-month period. Analysis was conducted collaboratively and iteratively around emergent themes, relating to the organisational work of technology adoption. Results: The two hospitals developed and implemented AKI CDSSs using very different approaches. Nevertheless, both resulted in adaptive work and trade-offs relating to the technology, the users, the organisation, and the wider system of care. A common tension was associated with attempts to maximise benefit whilst minimise additional burden. In both hospitals, resource pressures exacerbated the tensions of translating AKI recommendations into routine practice. Conclusions Our analysis highlights a conflicted relationship between external context (policy and resources), and organisational structure and culture (e.g. digital capability, attitudes to quality improvement). Greater consideration is required to the long-term effectiveness of the approaches taken, particularly in light of the ongoing need for adaptation to incorporate new practices into routine work

Understanding the implementation of 'sick day guidance' to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation

ObjectivesThe study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings.DesignQualitative semistructured interviews were conducted and comparative analysis informed by normalisation process theory was undertaken to understand sense-making, implementation and appraisal of the cards and associated guidance.SettingA single primary care health setting in the North of England.Participants29 participants took part in the qualitative evaluation: seven general practitioners, five practice nurses, five community pharmacists, four practice pharmacists, two administrators, one healthcare assistant and five patients.InterventionThe sick day guidance intervention was rolled out (2015–2016) in general practices (n=48) and community pharmacies (n=60). The materials consisted of a ‘medicine sick day guidance’ card, provided to patients who were taking the listed drugs. The card provided advice about medicines management during episodes of acute illness. An information leaflet was provided to healthcare practitioners and administrators suggesting how to use and give the cards.ResultsImplementation of sick day guidance cards to prevent AKI entailed a new set of working practises across primary care. A tension existed between ensuring reach in administration of the cards to at risk populations while being confident to ensure patient understanding of their purpose and use. Communicating the concept of temporary cessation of medicines was a particular challenge and limited their administration to patient populations at higher risk of AKI, particularly those with less capacity to self-manage.ConclusionsSick day guidance cards that focus solely on medicines management may be of limited patient benefit without adequate resourcing or if delivered as a standalone intervention. Development and evaluation of primary care interventions is urgently warranted to tackle the harm associated with AKI.</jats:sec