How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis

Abstract

BackgroundChronic kidney disease (CKD) is associated with increased cardiovascular mortality and morbidity as well as progression to established renal failure. Interventions in primary care, particularly the lowering of blood pressure in individuals with CKD and proteinuria and diabetes, can slow disease progression. This evidence base is codified in national guidance and in a simplified form in pay-forperformance targets. Prior to conducting the QICKD study -a cluster of quality-improvement interventions with reduction of blood pressure as its primary outcome measure -a diagnostic analysis was conducted to assess the relevance of the intended interventions. AimTo understand practitioners' views of CKD and its management. MethodFocus groups were held in five locations across England. Experienced facilitators developed a standardised approach and analysed data using the 'framework' approach.

Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study

“…Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions. initial themes raised by Crinson et al 8 and sought to identify processes underpinning the implementation of CKD management in primary care.…”

“…8 NPT provided a framework to explore in greater detail the interactional work that occurs in clinical encounters and within an organisation. 12,13 Practices participating in a CLAHRC CKD Collaborative were purposively sampled, 14 as this approach provided an opportunity to explore attempts to implement CKD management in primary care.…”

“…[5][6][7] A range of concerns have been raised by GPs, including difficulties associated with: assigning a diagnosis; the stigmatising effect of a diagnosis; explaining the concept of CKD to patients; achieving blood pressure targets; complicated medication regimens; and uncertainty about referral to secondary care. 8 The introduction of guidelines for the management of CKD requires a considerable change in behaviour by primary care clinicians. Changing professional behaviour is recognised as difficult and addressing the implementation gap requires an understanding of the reasons for resistance to change, and facilitators of change.…”

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

“…26 Underlying factors are that the GP's confidence in treating CKD is lower than in treating diabetes and hypertension, and that blood pressure targets in CKD are often regarded with scepticism. 27,28 A discussion is ongoing with regard to optimal blood pressure targets. 29 Systolic blood pressure of <120 mmHg is associated with stroke and diastolic blood pressure of <60 mmHg is associated with increased mortality in older people who are frail.…”

The role of primary care in managing chronic kidney disease

“…7 Utilising Editorials particular groups from the Cochrane Collaboration, they scoured the literature for evidence of changes in practice that lead to a clearly defined endpoint: the reduction of systolic blood pressure. They found only nine studies with significant rigour that demonstrated that changes in practice, nurse, or pharmacist can improve blood pressure control, which leads to better outcomes for these patients.…”