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

Abstract

BackgroundChronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care.MethodsA rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation.ResultsOur primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs.ConclusionsOur rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0413-7) contains supplementary material, which is available to authorized users.

Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet

“…51 Further research into the relationship between trust in the health professional and patient empowerment is warranted. [52][53][54] The implications of these study findings are both theoretical and practical. Given the high levels of professional frustration reported by renal dietitians in this study, it is important to ensure that they have regular professional supervision.…”

“…Furthermore, findings from a study of patients receiving dietary advice for cardiac rehabilitation indicated that patients stopped following dietary recommendations after receiving contradictory advice from other health professionals . Further research into the relationship between trust in the health professional and patient empowerment is warranted …”

The “realist search”: A systematic scoping review of current practice and reporting

“…We included a total of 35 studies in our sample . Most papers reported a single realist review (27 of 35).…”

Chronic kidney disease: identification and management in primary care

“…A useful summary is given by Taal, which summarizes the evidence for interventions such as eGFR reporting, enhanced prompts with eGFR, the role of pay for performance, audit-based education, and telemedicine 96. Features associated with successful implementation of CKD interventions in primary care include: framing CKD in the context of general well-being and vascular health as well as in terms of patient safety and medicines management; ensuring compatibility with existing clinical practice or with patient’s everyday lives; and enabling ownership of feedback processes to create individualized improvements 97. Other important considerations are clear mechanisms for CKD detection in those at risk as well as appropriate training for health practitioners, particularly in parts of the world where primary care may be less established but where CKD prevalence and impact are increasing 98…”