Intraprofessional boundary crossing in acute paediatric care: A rich journey for general practice and paediatric residents.

BACKGROUND: Achieving optimal collaboration between general practitioners and hospital-based critical care doctors is vital yet challenging, necessitating targeted collaborative training during residency. Despite apparent benefits, implementing intraprofessional learning faces constraints. Understanding its occurrence is crucial for engaging and educating residents. Considering boundaries' learning potential, we developed and evaluated an educational programme for general practitioner (GP) and paediatric (P) residents in paediatric emergency care based on Akkerman's Boundary Crossing Theory. The study investigated how intraprofessional learning mechanisms occurred and what learning conditions facilitated or impeded learning of GP and P residents, aiming to optimise educational programme design for intraprofessional collaboration. METHODS: We developed an educational programme with three activities: joint medical assessments of paediatric patients in each other's context, mutually mini-Clinical Evaluation Exercises (mini-CEXs) about intraprofessional collaboration skills and educational meetings about collaborative care. We performed a qualitative study with a constructivist approach to explore experiences of the programme. We conducted focus group interviews and analysed mini-CEXs, utilising Boundary Crossing theory for template analysis. RESULTS: Ten GP and eight P residents participated in our study. Learning mechanisms of identification and coordination dominated the joint medical assessments. Mini-CEXs stimulated reflection. Educational meetings with supervisors about intraprofessional barriers initiated transformation. Facilitated learning conditions were bidirectional crossing, enthusiastic supervisors, residents being familiar with each other, clear mini-CEX design and authentic paediatric cases. Unclear mutual expectations during joint medical assessments impeded learning of residents. CONCLUSIONS: Working in each other's context triggers learning mechanisms of identification, coordination and reflection, forming the basis for intraprofessional learning in paediatric emergency care for GP and P residents. For development of new collaboration practices, supervisors are necessary to translate reflection into transformation. Mutual responsibilities and expectations should be made more explicit to create a safer intraprofessional learning environment. Our findings extend to other medical training contexts, leveraging boundaries for learning.

How does portfolio use support self-regulated learning during general practitioner specialty training? A qualitative focus group study.

OBJECTIVES: Portfolios are used to support self-regulated learning (SRL), but the research literature is still inconclusive on their effectiveness. This study explored experiences with portfolio use among different stakeholders, to answer the research question: How does portfolio use support SRL during general practitioner (GP) specialty training? DESIGN: We used a qualitative research design, based on phenomenology. SETTING: Three of the eight training institutes of Dutch GP specialty training participated in this study. PARTICIPANTS: The three stakeholder groups that use the portfolio were included in nine homogenous focus groups: trainees (n=16), supervisors (n=16) and faculty (n=17). All participants had at least 6-month experience with portfolio use. RESULTS: Three themes were identified: SRL with(out) the portfolio, stakeholder dynamics and ambiguities. Respondents were doubtful about the learning benefits of portfolio use, as most trainees used their portfolio to 'check off' what was considered required. Stakeholder dynamics contributed to checking off behaviour in two ways. First, trainees experienced documenting learning activities to be superfluous, since the close relationship with their supervisor already supported SRL sufficiently. Second, faculty often (unintentionally) took portfolio ownership away from trainees, as they instructed trainees to deliver portfolio content that was valuable for assessment. Without ownership, trainees struggled to use the portfolio for SRL. Besides, ambiguities related to portfolio use amplified checking off behaviour. CONCLUSIONS: Portfolio use did not support SRL in our setting. The multipurpose use of the portfolio (for the support of SRL and assessment) was identified as the primary obstacle. Underlying is a conflict that is often present in current medical curricula: agency versus accountability. If the support of SRL is considered a valuable and attainable purpose of portfolio use, it is important to realise that deliberate attention for this purpose is required during the design, guidance, assessment and evaluation of the portfolio.

How does portfolio use affect self-regulated learning in clinical workplace learning: What works, for whom, and in what contexts?

INTRODUCTION: Portfolio use to support self-regulated learning (SRL) during clinical workplace learning is widespread, but much is still unknown regarding its effectiveness. This review aimed to gain insight in the extent to which portfolio use supports SRL and under what circumstances. METHODS: A realist review was conducted in two phases. First, stakeholder interviews and a scoping search were used to formulate a program theory that explains how portfolio use could support SRL. Second, an in-depth literature search was conducted. The included papers were coded to extract context-mechanism-outcome configurations (CMOs). These were synthesized to answer the research question. RESULTS: Sixteen papers were included (four fulfilled all qualitative rigor criteria). Two primary portfolio mechanisms were established: documenting as a moment of contemplation (learners analyze experiences while writing portfolio reports) and documentation as a reminder of past events (previous portfolio reports aid recall). These mechanisms may explain the positive relationship between portfolio use and self-assessment, reflection, and feedback. However, other SRL outcomes were only supported to a limited extent: formulation of learning objectives and plans, and monitoring. The partial support of the program theory can be explained by interference of contextual factors (e.g., system of assessment) and portfolio-related mechanisms (e.g., mentoring). DISCUSSION: Portfolio research is falling short both theoretically-in defining and conceptualizing SRL-and methodologically. Nevertheless, this review indicates that portfolio use has potential to support SRL. However, the working mechanisms of portfolio use are easily disrupted. These disruptions seem to relate to tensions between different portfolio purposes, which may undermine learners' motivation.

Reaching consensus on GP interprofessional competencies: a nominal group study.

BACKGROUND: As the requirements for collaboration in primary care increase, effective interprofessional teamwork between GPs and other primary care professionals is crucial. The need for more training in interprofessional collaborative competencies is widely recognised. However, existing competency frameworks do not sufficiently specify interprofessional collaboration to guide interprofessional competency development. AIM: To reach consensus among GPs and other primary care professionals on interprofessional competencies that GP and GP trainees should learn. DESIGN & SETTING: A qualitative consensus study among Dutch GPs and other primary care professionals, all with expertise in primary care interprofessional collaborative practice. METHOD: Three nominal group sessions were held, each resulting in its own group consensus on GP interprofessional collaborative competencies. The researchers conducted a content analysis to merge and thematise the prioritised competencies into one list. Participants prioritised this list of competencies. A pre-set cut-off point was applied to determine the overall consensus on core GP interprofessional competencies. RESULTS: Eighteen professionals from nine different disciplines participated. The content analysis resulted in 31 unique competencies, of which 14 competencies were prioritised in the final ranking into the following three main themes: (1) professional identity development and role definition by the GP (three competencies); (2) developing and executing shared care plans for individual patients (six competencies); and (3) initiating and maintaining interprofessional collaborative partnerships (five competencies). CONCLUSION: An interprofessional group of experts reached consensus on 14 competencies within three themes. This framework provides a stepping stone for GPs to focus on their development regarding interprofessional collaboration.

Referring patients with stable moderate-to-advanced chronic kidney disease back to primary care: a feasibility study.

BACKGROUND: Care for patients with chronic kidney disease (CKD) necessitates tailored pathways between primary and secondary care. It is unknown if back referring patients with CKD is safe and effective. AIM: To study the feasibility of discharging patients with stable moderate-to-advanced CKD from secondary to primary care, and to evaluate quality of care (QoC) and patients' and GPs' experiences. DESIGN & SETTING: A monocentre prospective mixed-method study in the Netherlands. METHOD: Patients were included who met pre-determined back-referral (BR) criteria. Patients were discharged with personalised information guides and transfer letters. GPs had the option of consulting a nephrologist by telenephrology. Renal outcomes, QoC, and experiences were collected after 1 year. RESULTS: Eighteen patients were included. The mean age was 73 years; the mean estimated glomerular filtration rate (eGFR) was 33.2 ml/min/1.73 m2 at baseline. After 1 year, four patients had received either no or incomplete monitoring, and one patients' blood pressure was too high. The remaining 13 had stable eGFR, proteinuria, and metabolic parameters. Patients were satisfied with information provision and treatment by GPs but expected more frequent monitoring. In one-third of cases, monitoring frequency was decreased by GPs for several reasons. GPs believed they had sufficient knowledge to treat patients with CKD, but indicated they needed support besides a transfer letter. CONCLUSION: BR seems safe and feasible for patients with stable moderate-to-advanced CKD who meet specific criteria. Patients have good renal outcomes after 1 year and are satisfied with treatment. GP QoC can be improved, particularly completeness and monitoring frequency.

Exploring power dynamics and their impact on intraprofessional learning.

BACKGROUND: During postgraduate training, considerable efforts for intraprofessional education are in place to prepare primary care residents (PC residents) and medical specialty residents (MS residents) for intraprofessional collaboration (intraPC). Power dynamics are inherently present in such hierarchical medical contexts. This affects intraPC (learning). Yet little attention has been paid to factors that impact power dynamics. This study aims to explore power dynamics and their impact on intraPC learning between PC residents and MS residents during hospital placements. METHODS: This study expands on previously published ethnographic research investigating opportunities and barriers for intraPC learning among residents in five Dutch hospitals. We analysed transcripts of observations and in-depth interviews using template analysis. A critical theory paradigm was employed. Discourse analysis additionally informed the data. RESULTS: We defined five interrelated themes that describe characteristics of power dynamics in intraPC learning during hospital placements: beliefs; power distribution; interaction style; subjection; and fearless learning. Power dynamics operate both within and between the themes: power distribution between PC residents, MS residents and MS supervisors seemed to be an attribution affected by underlying beliefs about professional norms or about other professions; beliefs influenced the way PC residents, MS residents and MS supervisors interacted; power distribution based on inequity could lead to subjection of PC residents; power distribution based on equity could lead to fearless learning; and open interactions enabled fearless intraPC learning. CONCLUSIONS: Power dynamics have an impact on intraPC learning among residents in hospitals. Constructive power dynamics occur when power distribution is based on equity, combined with sincere open interactions, actively inviting each other into discussions and enlisting the support of MS supervisors to foster fearless learning. This can be achieved by creating awareness of implicit beliefs and making them explicit, recognising interaction that encourages intraPC learning and creating policies that support fearless intraPC learning.

Intraprofessional workplace learning in postgraduate medical education: a scoping review.

BACKGROUND: Residents need to be trained across the boundaries of their own specialty to prepare them for collaborative practice. Intraprofessional learning (i.e. between individuals of different disciplines within the same profession) has received little attention in the postgraduate medical education literature, in contrast to the extensive literature on interprofessional learning between individuals of different professions. To address this gap, we performed a scoping review to investigate what and how residents learn from workplace-related intraprofessional activities, and what factors influence learning. METHODS: The PRISMA guidelines were used to conduct a scoping review of empirical studies on intraprofessional workplace learning in postgraduate medical education published between 1 January 2000 to 16 April 2020 in Pubmed, Embase, PsycINFO, ERIC and Web of Science. This study applied 'best fit' framework-based synthesis to map the existing evidence, using the presage-process-product (3P) model developed by Tynjälä (2013). RESULTS: Four thousand three hundred thirty records were screened, and 37 articles were included. This review identified influencing (presage) factors that derived from the sociocultural environment, learner and learning context. Studies described that complexity of care can both facilitate and hinder learning. Furthermore, intraprofessional learning is threatened by professional stereotyping and negative perceptions, and awareness of learning opportunities and explicit reflection are critical in intraprofessional workplace learning. Studies described a range of informal and formal intraprofessional activities (process) under the headings of collaboration in clinical practice, rotations or placements, formal educational sessions and simulated workplace training. In general, learners responded well and their attitudes and perceptions improved, learners reported increased knowledge and skills and positive behavioural changes (product). Learning outcomes were reported in the domains of patient-centred care, collaborative attitudes and respect, mutual knowledge and understanding, collaborative decision making, communication, leadership, teamwork and reflexivity. CONCLUSIONS: This review gives insight into the high learning potential of intraprofessional activities. Many of the included studies relied on self-reported perceptions of change, therefore, future research should focus on generating more robust evidence including objectively examined outcome measures. This review offers a comprehensive overview of the factors that influence intraprofessional workplace learning in postgraduate medical education. Finally, we provide recommendations for enhancing intraprofessional learning in clinical practice.

General practitioners' views on the influence of long-term care reforms on integrated elderly care in the Netherlands: a qualitative interview study.

This study explores the long-term care (LTC) reform in the Netherlands and its relation to the day-to-day integrated care for frail elderly people, from the perspective of general practitioners (GPs). We assessed GP perspectives regarding which elements of the LTC reform have promoted and hindered the provision of person-centred, integrated care for elderly people in the Netherlands. We performed case studies conducted by semi-structured interviews, using the Healthy Alliances (HALL) framework as a framework for thematic analysis. GPs reported that the ideals of the LTC reform (self-reliance) were largely achievable and listed a number of positive effects, including increased healthcare professional engagement and the improved integration of the medical and social domains through the close involvement of social support teams. The reported negative implications were a lack of co-ordination in the implementation of the reforms by the municipality, insufficient funding for multidisciplinary team meetings and the reinforced fragmentation of home care. In particular, the implementation of the system reforms took place with little regard for the local context. We suggest that the implementation of national care reforms should be aligned with factors operating at the micro level and make the following recommendations: use one central location for primary health and social services, integrate regional ICT structures to improve the exchange of patient information, and reduce fragmentation in home care.

Competencies for collaboration between general practitioners and medical specialists: a qualitative study of the patient perspective.

OBJECTIVES: To explore the patient view of competencies essential for doctors to provide good collaboration at the primary-secondary care interface. DESIGN: We used a qualitative research approach. Focus groups with patients were conducted to explore their opinions of doctors' competencies to provide good collaboration between primary and secondary care doctors. Transcripts were analysed using thematic analysis. SETTING: Dutch primary-secondary care interface. PARTICIPANTS: Sixteen participants took part in five focus groups. Patients treated in both primary and secondary care, defined as having a minimum of two contacts with their general practitioner and two contacts with a medical specialty in the last 6 months, were included. Psychiatric patients and children were excluded from this study. RESULTS: Three groups of competencies were identified: (1) relationship building, both with patients and with other doctors; (2) transparent collaborating: be able to provide clarity on the process of collaboration and on roles and responsibilities of those involved and (3) reflective practising: to be willing to acknowledge mistakes, give and receive feedback and act as a lifelong learner. CONCLUSIONS: This focus group study enhances our understanding of the patient perspective on doctors' collaborative competencies at the primary-secondary care interface. With this information, doctors can improve their collaborative skills to a level that would meet their patients' needs. Patients expect doctors to be able to build relationships and act as reflective practitioners. Including patients in the collaborative process by giving them a role that is appropriate to their abilities and by making collaboration more explicit could help to improve collaboration between general practitioners and medical specialists.

Chances for learning intraprofessional collaboration between residents in hospitals.

CONTEXT: Intraprofessional collaboration (intraPC) between primary care (PC) doctors and medical specialists (MSs) is becoming increasingly important. Patient safety issues are often related to intraPC. In order to equip doctors well for their task of providing good quality and continuity of care, intraPC needs explicit attention, starting in postgraduate training. Worldwide, PC residents undertake a hospital placement during their postgraduate training, where they work in proximity with MS residents. This placement offers the opportunity to learn intraPC. It is yet unknown whether and how residents learn intraPC and what barriers to and opportunities for exist in learning intraPC during hospital placements. METHODS: We performed an ethnographic non-participatory observational study in three emergency departments and three geriatric departments of five hospitals in the Netherlands. This was followed by 42 in-depth interviews with the observed residents and supervisors. The observations were used to feed the questions for the in-depth interviews. We analysed the interviews iteratively following the data collection using template analysis. RESULTS: Hospital wards are rich in opportunities for learning intraPC. These opportunities, however, are seldom exploited for various reasons: intraPC receives limited attention when formulating placement goals, so purposeful learning of intraPC hardly takes place; residents lack awareness of the learning of intraPC; MS residents are not accustomed to searching for expertise from PC residents; PC residents adapt to the MS role and they contribute very little of their PC knowledge, and power dynamics in the hospital department negatively influence the learning of intraPC. Therefore, improvements in mindset, professional identity and power dynamics are crucial to facilitate and promote intraPC. CONCLUSIONS: Intraprofessional collaboration is not learned spontaneously during hospital placements. To benefit from the abundant opportunities to learn intraPC, adjustments to the set-up of these placements are necessary. Learning intraPC is promoted when there is a collaborative culture, hierarchy is limited, and there is dedicated time for intraPC and support from the supervisor.

What Patients with Mild-to-Moderate Kidney Disease Know, Think, and Feel about Their Disease: An In-Depth Interview Study.

INTRODUCTION: It is unknown what patients in primary care with mild-to-moderate chronic kidney disease (CKD) know, think, and feel about their diagnoses and how they value the information provided. The aim of the study was to explore their knowledge, thoughts, and experiences concerning their CKD and the information given to them. METHOD: Qualitative interview study with patients with mild-to-moderate CKD who know their diagnoses and are treated mainly by family physicians. RESULTS: Four themes arose: CKD literacy, coping with anxiety, prerequisites for self-management, and reciprocity in information provision. The participants filled deficiencies in their CKD knowledge with misconceptions and half-truth about causes, symptoms, and treatment. The anxiety about CKD at the time of diagnosis versus the feeling of irrelevance later on was due to the absence of CKD symptoms and their physicians' minimization of the seriousness of CKD. Participants failed to connect lifestyle and cardiovascular disease with CKD. Not all participants were well informed about the consequences that CKD might have. CKD literacy and willingness to change were both necessary to accept lifestyle changes. Further, the participants felt that it would be helpful when information comes with empathy and is tailored to patients' personal needs. CONCLUSIONS: Patients have various perceptions about their CKD. Exploring these perceptions could help match their needs with better-tailored information. Doctors should be aware that they can deliver inaccurate signals about CKD severity, so that patients fail to realize the potential impact of CKD. This makes them less open to lifestyle changes and improving their self-management.

General practitioners' perspectives on management of early-stage chronic kidney disease: a focus group study.

BACKGROUND: Guideline adherence in chronic kidney disease management is low, despite guideline implementation initiatives. Knowing general practitioners' (GPs') perspectives of management of early-stage chronic kidney disease (CKD) and the applicability of the national interdisciplinary guideline could support strategies to improve quality of care. METHOD: Qualitative focus group study with 27 GPs in the Netherlands. Three analysts open-coded and comparatively analysed the data. Mind-mapping sessions were performed after data-saturation. RESULTS: Five themes emerged: defining CKD, knowledge and awareness, patient-physician interaction, organisation of CKD care and value of the guideline. A key finding was the abstractness of the CKD concept. The GPs expressed various perspectives about defining CKD and interpreting estimated glomerular filtration rates. Views about clinical relevance influenced the decision-making, although factual knowledge seems lacking. Striving to inform well enough without creating anxiety and to explain suitably for the intellectual ability of the patient caused tension in the patient-physician interaction. Integration with cardiovascular disease-management programmes was mentioned as a way of implementing CKD care in the future. The guideline was perceived as a rough guide rather than a leading document. CONCLUSION: CKD is perceived as an abstract rather than a clinical concept. Abstractness plays a role in all formulated themes. Management of CKD patients in primary care is complex and is influenced by physician-bound considerations related to individual knowledge and perception of the importance of CKD. Strategies are needed to improve GPs' understanding of the concept of CKD by education, a holistic approach to guidelines, and integration of CKD care into cardiovascular programmes. TRIAL REGISTRATION: Not applicable.

Learning intraprofessional collaboration by participating in a consultation programme: what and how did primary and secondary care trainees learn?

BACKGROUND: A growing number of patients require overview and management in both primary and secondary care. This situation requires that primary and secondary care professionals have well developed collaborative skills. While knowledge about interprofessional collaboration and education is rising, little is known about intraprofessional collaboration and education between physicians of various disciplines. This study examines a newly developed consultation programme for trainees in general practice and internal medicine to acquire intraprofessional collaboration skills. METHODS: Focus groups were conducted with trainees and their supervisors and mentors to explore what and how the trainees learned by participating in the consultation programme. RESULTS: Trainees reported that they gained knowledge about and skills in collaboration and consultation they could not have gained otherwise. Furthermore, the programme gave the opportunity to gain other competencies relevant for becoming the medical expert trainees they are expected to be. Learning outcomes were comparable to those described in interprofessional education literature. Interaction, by meeting each other and by discussing cases with mentors or supervisors, appeared to be a key factor in the learning process. Meetings, discussing preconceptions and enthusiasm of the mentors and supervisors facilitated the learning. Technical problems and lack of information hampered the learning. These influencing factors are important for future development of intraprofessional learning programmes. CONCLUSIONS: Participants in an innovative consultation programme for GP- and IM-trainees reported that they acquired consultation and collaboration skills they could not have gained otherwise. Interaction appeared to be an important factor in the learning process. The findings of this study can inform developers of intraprofessional education programmes between primary and secondary care trainees.

Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial.

Background: Consultation of a nephrologist is important in aligning care for patients with chronic kidney disease (CKD) at the primary-secondary care interface. However, current consultation methods come with practical difficulties that can lead to postponed consultation or patient referral instead. Objective: This study aimed to investigate whether a web-based consultation platform, telenephrology, led to a lower referral rate of indicated patients. Furthermore, we assessed consultation rate, quality of care, costs and general practitioner (GPs') experiences with telenephrology. Methods: Cluster randomized controlled trial with 47 general practices in the Netherlands was randomized to access to telenephrology or to enhanced usual care. A total of 3004 CKD patients aged 18 years or older who were under primary care were included (intervention group n = 1277, control group n = 1727) and 2693 completed the trial. All practices participated in a CKD management course and were given an overview of their CKD patients. Results: The referral rates amounted to 2.3% (n = 29) in the intervention group and 3.0% (n = 52) in the control group, which was a non-significant difference, OR 0.61; 95% CI 0.31 to 1.23. The intervention group's consultation rate was 6.3% (n = 81) against 5.0% (n = 87) (OR 2.00; 95% CI 0.75-5.33). We found no difference in quality of care or costs. The majority of GPs had a positive opinion about telenephrology. Conclusion: The data in our study do not allow for conclusions on the effect of telenephrology on the rate of patient referrals and provider-to-provider consultations, compared to conventional methods. It was positively evaluated by GPs and was non-inferior in terms of quality of care and costs.

Adherence to chronic kidney disease guidelines in primary care patients is associated with comorbidity.

Background: GPs insufficiently follow guidelines regarding consultation and referral for chronic kidney disease (CKD). Objective: To identify patient characteristics and quality of care (QoC) in CKD patients with whom consultation and referral recommendations were not followed. Method: A 14 month prospective observational cohort study of primary care patients with CKD stage 3-5. 47 practices participated, serving 207469 people. 2547 CKD patients fulfilled consultation criteria, 225 fulfilled referral criteria. We compared characteristics of patients managed by GPs with patients receiving nephrologist co-management. We assessed QoC as adherence to monitoring criteria, CKD recognition and achievement of blood pressure (BP) targets. Results: Patients treated in primary care despite a consultation recommendation (94%) had higher eGFR values (OR 1.07; 95% CI: 1.05-1.09), were less often monitored for renal function (OR 0.42; 95% CI: 0.24-0.74) and potassium (OR 0.56; 95% CI: 0.35-0.92) and CKD was less frequently recognised (OR 0.46; 95% CI: 0.31-0.68) than in patients with nephrologist co-management. Patients treated in primary care despite referral recommendation (70%) were older (OR 1.03; 95% CI:1.01-1.06) and had less cardiovascular disease (OR 0.37; 95% CI: 0.19-0.73). Overall, in patients solely managed by GPs, CKD recognition was 50%, monitoring disease progression in 36% and metabolic parameters in 3%, BP targets were achieved in 51%. Monitoring of renal function and BP was positively associated with diabetes (OR 3.10; 95% CI: 2.47-3.88 and OR 7.78; 95% CI: 3.21-18.87) and hypertension (OR 3.19; 95% CI: 2.67-3.82 and OR 3.35; 95% CI: 1.45-7.77). Conclusion: Patients remaining in primary care despite nephrologists' co-management recommendations were inadequately monitored, and BP targets were insufficiently met. CKD patients without cardiovascular comorbidity or diabetes require extra attention to guarantee adequate monitoring of renal function and BP.

Communities of practice: A means to support occupational therapists' continuing professional development. A literature review.

BACKGROUND: This literature review investigates what research reports about the contribution that communities of practice (CoPs) can make in the continuing professional development (CPD) of qualified occupational therapists. METHODS: Academic databases (CINAHL, MEDLINE and ERIC) were searched and articles were included based on pre-determined criteria. Five articles were included in the review. RESULTS: The CoPs in the reviewed articles provided opportunities for knowledge sharing, knowledge translation, reflection on action and learning through boundary crossing. The presence of professionals with diverse perspectives was an important ingredient that facilitated CPD. CONCLUSION: Research into the use of CoPs in occupational therapy is sparse. CoPs could provide a CPD forum for occupational therapists whether online or face to face. Practitioners are encouraged to participate in CoPs. Further research into the use of CoPs is recommended.

What is the relationship between renal function and visit-to-visit blood pressure variability in primary care? Retrospective cohort study from routinely collected healthcare data.

OBJECTIVE: To determine the relationship between renal function and visit-to-visit blood pressure (BP) variability in a cohort of primary care patients. DESIGN: Retrospective cohort study from routinely collected healthcare data. SETTING: Primary care in Nijmegen, the Netherlands, from 2007 to 2012. PARTICIPANTS: 19 175 patients who had a measure of renal function, and 7 separate visits with BP readings in the primary care record. OUTCOME MEASURES: Visit-to-visit variability in systolic BP, calculated from the first 7 office measurements, including SD, successive variation, absolute real variation and metrics of variability shown to be independent of mean. Multiple linear regression was used to analyse the influence of estimated glomerular filtration rate (eGFR) on BP variability measures with adjustment for age, sex, diabetes, mean BP, proteinuria, cardiovascular disease, time interval between measures and antihypertensive use. RESULTS: In the patient cohort, 57% were women, mean (SD) age was 65.5 (12.3) years, mean (SD) eGFR was 75.6 (18.0) mL/min/1.73m(2) and SD systolic BP 148.3 (21.4) mm Hg. All BP variability measures were negatively correlated with eGFR and positively correlated with age. However, multiple linear regressions demonstrated consistent, small magnitude negative relationships between eGFR and all measures of BP variability adjusting for confounding variables. CONCLUSIONS: Worsening renal function is associated with small increases in measures of visit-to-visit BP variability after adjustment for confounding factors. This is seen across the spectrum of renal function in the population, and provides a mechanism whereby chronic kidney disease may raise the risk of cardiovascular events.