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.

Kidney Research UK's: a better life through education and empowerment.

Over 3 million people are affected by chronic kidney disease (CKD). Kidney Research UK, a national charity dedicated to research that will lead to better treatment and cures for kidney disease has developed the innovative and successful 'A better life through education and empowerment' (ABLE) programme which researches and raises awareness of the issues among 'at risk' groups and helps prevent or slow its progression. Initially the programme focused on the black and minority ethnic (BME) communities who are up to 5 times more likely to develop kidney failure than white caucasians. This is largely due to hypertension and type 2 diabetes. Recently the scope of the programme was broadened to encompassall those at risk and the useful lessons learned from the 7 initial projects are being used to inform the future of ABLE and other CKD projects. The programme has been funded by a cross section of organizations including the Department of Health and the Big Lottery Fund. Outcomes from the first two completed projects as well as an update on the other ABLE work are summarized.

An overview of chronic kidney disease management and CAPD in the home.

Chronic kidney disease (CKD) is a common, harmful, but treatable long term condition. An overview of CKD is provided in this article. Kidney Research UK, www.kidneyresearchuk.org a national charity dedicated to research, has developed the A Better Life through Education and empowerment (ABLE) programme which seeks to research and raise awareness o the issues among 'at risk' groups as well as among relevant health professionals. Part Two of the renal NSF suggests many actions that can be taken in primary care to prevent CKD. In the event of Established Renal Failure (ERF), there are a number of treatment options available including continuous ambulatory peritoneal dialysis (CAPD), described here. Kidney Research UK's Patient DVD module two (complimentary copy attached to this issue) provides more detail using case studies. The DVD offers practical help, support and guidance on how to overcome some of the challenges.

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.

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 UK's 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.

A quality improvement project to improve the effectiveness and patient-centredness of management of people with mild-to-moderate kidney disease in primary care.

Chronic kidney disease (CKD) stages 3 to 5, affects 6-7% of the adult population and is an important risk factor for both advanced kidney disease and cardiovascular disease. This paper describes a quality improvement project that aimed to establish consistent implementation of best practice in people with stage 3-5 kidney disease who were managed in primary care. The intervention was a Care Bundle for CKD. The bundle included three evidence-based, high impact interventions based on National Institute for Care Excellence (NICE, 2008) guidance, with an additional and novel self-management element. 29 GP Practices in England and Wales began the study. They undertook training in clinical management of CKD and in facilitation of self-management, with the self-management content designed and led by patients. Practices were asked to report baseline and then monthly outcome data extracted from practice computer systems. The project team provided implementation and ongoing quality improvement support for participating Practices. Ten Practices dropped out of the study following the training. Data submissions were incomplete in six Practices who continued to apply the care bundle. At the project end, a decision was taken by the study team to perform the final analysis on those thirteen Practices which completed the project and submitted at least six sets of monthly Practice-level outcome data. In these Practices the Care Bundle was applied to under 20% of the registered CKD stage 3 to 5 population in 5 Practices, 20-29% in 3 Practices, 30-49% in 2 Practices and ≥50% in 3 Practices (998 patients in total). Of these, 671 patients (75%) agreed to the self-management component of the intervention. The reliability (at project end) in those who received the Bundle was 100%. The Bundle was applied to an additional 315 patients in the six Practices who completed the project but did not submit regular practice-level monthly data. In the thirteen remaining Practices, the achievement of NICE (2008) blood pressure targets at the start of the project was 74.8% in people with CKD stage 3-5 and no diabetes and 48% in people with CKD stage 3-5 and diabetes. At the project end these figures in the same Practices were 76.7% and 49.2% respectively. These improvements were achieved in spite of Practices increasing their recording of prevalence rate (that is, identifying and recording more patients with CKD on the Practice CKD Register). In conclusion, a care bundle can be implemented in primary care. However, maintaining engagement with primary care health care professionals and maximising exposure to an intervention in patients seen infrequently are significant challenges to generalisation and sustainability.

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.

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.

BACKGROUND: Chronic 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 progression DESIGN: Cluster randomised controlled trial (CRT) METHODS: This 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 REGISTRATION: ISRCTN56023731. ClinicalTrials.gov identifier.

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.