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.

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.

Person-centred care is internationally recognised as best practice for the care of people with dementia. Personal information documents for people with dementia are proposed as a way to support person-centred care in healthcare settings. However, there is little research about how they are used in practice. The aim of this study was to analyse healthcare staff 's perceptions and experiences of using personal information documents, mainly Alzheimer's Society's 'This is me', for people with dementia in healthcare settings. The method comprised a secondary thematic analysis of data from a qualitative study, of how a dementia awareness initiative affected care for people with dementia in one healthcare organisation. The data were collected through 12 focus groups (n = 58 participants) and 1 individual interview, conducted with a range of healthcare staff, both clinical and non-clinical. There are four themes presented: understanding the rationale for personal information documents; completing personal information documents; location for personal information documents and transfer between settings; impact of personal information documents in practice. The findings illuminated how healthcare staff use personal information documents in practice in ways that support person-centred care. Practical issues about the use of personal information documents were revealed and these may affect the optimal use of the documents in practice. The study indicated the need to complete personal information documents at an early stage following diagnosis of dementia, and the importance of embedding their use across care settings, to support communication and integrated care.

PurposePeople who are living with dementia are core health service users but there are ongoing concerns about the quality of their care and the need for improved education of healthcare staff. This paper reports on a qualitative study that investigated staff perspectives of an ethnodrama ('Barbara's Story') which was used to educate an entire health service workforce and promote a person-centred approach to care. Design/Methodology/ApproachThe study used a qualitative, longitudinal design with focus groups held with clinical (nurses, allied health professionals, medical) and non-clinical staff. In Phase 1 there were 10 focus groups (n=67 participants) and one individual interview. In Phase 2 there were 16 focus groups (n=77 participants) and three individual interviews. FindingsBarbara's Story raised awareness of dementia, engaged staff emotionally and prompted empathetic responses and improved interactions. The project's senior leadership, whole organisation and mandatory approach were well-supported, with a perceived impact on organisational culture. The project helped to embed practice developments and initiatives to support person-centred care. Barbara's story is now well integrated into the organisation, thus supporting sustainability. Originality/valueWhilst there are increasing resources for educating about dementia, there are fewer evaluations, particularly for large-scale initiatives, and there is a lack of focus on long-term effects. The study findings indicate that education about dementia can be delivered to a whole work force in a sustainable manner, to prompt empathy, raise awareness, support person-centred care and impact on individual behaviour and organisational culture.

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.