Barriers and facilitators to opportunistic chronic kidney disease screening by general practice nurses

The CKD-DETECT V2.0 study: A randomised controlled trial evaluating the effectiveness of an infographic poster compared with an e-learning program on general practice nurses' knowledge and learning efficiency about chronic kidney disease risk factors and best practice screening procedures

AIMS AND OBJECTIVES

To evaluate: (a) the effectiveness of an infographic poster compared with an e-learning program on general practice nurses' knowledge about chronic kidney disease risk factors and best practice screening procedures and (b) the effectiveness of an infographic poster compared with an e-learning program on general practice nurses' learning time and learning efficiency.

BACKGROUND

The screening and early detection of chronic kidney disease is essential in reducing its burden on the health system and those affected by it. General practice nurses are well-positioned to assist in its early detection.

DESIGN

Parallel-group, single-blinded, pre-post interventional randomised control design.

METHOD

This study was reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Participants were registered or enrolled nurses working in general practice settings across Australia. The intervention group (n = 173) received an infographic poster about chronic kidney disease risk factors and best practice screening procedures, whereas the control group (n = 170) received an interactive e-learning program. Data were collected using an 8-item pre-post knowledge evaluation instrument. Time spent learning were collected through a self-reported log and a login/logout method.

RESULTS

The overall intervention effect demonstrated no statistical significance in knowledge scores from the baseline scores between the intervention and control group. The intervention group demonstrated higher learning efficiency in comparison to the control group.

CONCLUSION

The study demonstrated an infographic poster is as effective as an e-learning program on improving knowledge scores. However, in comparison to an e-learning program, an infographic poster is a more efficient way of learning.

RELEVANCE TO CLINICAL PRACTICE

Infographic posters can be an efficient educational modality to enhance healthcare professionals' knowledge and could be used as public health campaigns in clinical settings to educate the community.

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

Background

Chronic kidney disease (CKD) is growing population health concern worldwide, and with early identification and effective management, kidney disease progression can be slowed or prevented. Most patients with risk factors for chronic kidney disease are treated within primary healthcare. Therefore, it is important to understand how best to support primary care providers (PC-P) to detect and manage chronic kidney disease. The aim of this systematic review was to evaluate barriers and enablers to the diagnosis and management of CKD in primary care.

Methods

A systematic review of qualitative research on the barriers and/or enablers to detection and/or management of CKD in adults within primary healthcare was conducted. The databases Medline (EBSCO), PubMed, Cochrane CENTRAL, CINAHL (EBSCO) and Joanna Briggs Institute Evidence Based Practice (Ovid) were searched until 27th August 2019. Barriers and/or enablers reported in each study were identified, classified into themes, and categorised according to the Theoretical Domains Framework.

Results

A total of 20 studies were included in this review. The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the ‘Environmental context and resources’ domain (n = 16 studies). Overall, the most common barrier identified was a lack of time (n = 13 studies), followed by a fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines (both n = 10 studies). Overall, the most common enabler identified was the presence of supportive technology to identify and manage CKD (n = 7 studies), followed by the presence of a collaborative relationship between members of the healthcare team (n = 5 studies).

Conclusion

This systematic review identified a number of barriers and enablers which PC-P face when identifying and managing CKD. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently co-morbid nature of CKD. Enhanced collaboration between PC-P and nephrology services may also support PC-Ps when diagnosing CKD in primary care, and facilitate improved patient self-management.

How do general practitioners access guidelines and utilise electronic medical records to make clinical decisions on antibiotic use? Results from an Australian qualitative study

OBJECTIVE

This study aimed to explore how general practitioners (GPs) access and use both guidelines and electronic medical records (EMRs) to assist in clinical decision-making when prescribing antibiotics in Australia.

DESIGN

This is an exploratory qualitative study with thematic analysis interpreted using the Theory of Planned Behaviour (TPB) framework.

SETTING

This study was conducted in general practice in Victoria, Australia.

PARTICIPANTS

Twenty-six GPs from five general practices were recruited to participate in five focus groups between February and April 2018.

RESULTS

GPs expressed that current EMR systems do not provide clinical decision support to assist with antibiotic prescribing. Access and use of guidelines were variable. GPs who had more clinical experience were less likely to access guidelines than younger and less experienced GPs. Guideline use and guideline-concordant prescribing was facilitated if there was a practice culture encouraging evidence-based practice. However, a lack of access to guidelines and perceived patients' expectation and demand for antibiotics were barriers to guideline-concordant prescribing. Furthermore, guidelines that were easy to access and navigate, free, embedded within EMRs and fit into the clinical workflow were seen as likely to enhance guideline use.

CONCLUSIONS

Current barriers to the use of antibiotic guidelines include GPs' experience, patient factors, practice culture, and ease of access and cost of guidelines. To reduce inappropriate antibiotic prescribing and to promote more rational use of antibiotic in the community, guidelines should be made available, accessible and easy to use, with minimal cost to practicing GPs. Integration of evidence-based antibiotic guidelines within the EMR in the form of a clinical decision support tool could optimise guideline use and increase guideline-concordant prescribing.

The CKD-DETECT study: An RCT aimed at improving intention to initiate a kidney health check in Australian practice nurses

BACKGROUND

The burden of Chronic Kidney Disease (CKD) on the Australian health system is growing. Efforts to reverse this trend have not been successful. This paper evaluates the effectiveness of a targeted asynchronous web based e-learning module on general practice nurses' behavioural intentions in relation to opportunistic screening practices for people at risk of CKD.

DESIGN

Double blinded pre-post interventional randomised control design.

METHODS

Participants were nurses working in general practice settings in Australia. Participants were randomised to a knowledge based active control or targeted behavioural based intervention which were delivered using asynchronous e-learning modules. The intervention was designed to influence the behavioural constructs of the theory of planned behaviour (TPB): attitude, subjective norm and perceived behavioural control (PBC).

RESULTS

Of the 420 participants, we analysed the primary and secondary outcomes for 212 (50.47%) who had complete follow up data. There were no significant differences (p 0.424, [d] 0.04) in behavioural intention between the intervention and control groups at follow-up, when controlling for baseline values. However, regression models assessing the relationship between the change in the TPB constructs and behavioural intention at follow-up for all participants, regardless of study arm, demonstrated a significant change in intention to initiate a kidney health check. Although these changes could not be attributed to the effect of the intervention. Attitude (r2 = 0.3525, p 0.0004) and PBC (r2 = 0.3510, p 0.0005) models accounted for approximately 35% of the explained variance in behavioural intentions and social norm (r2 = 0.3297, p 0.0171) accounted for approximately 33% of the variance. When all TPB constructs were included in the model, 37% of the variance in intention was explained.

CONCLUSION

A targeted behavioural online intervention was no more effective than a knowledge based online program to improve primary health care nurses' intention to initiate a kidney health check in people at risk of chronic kidney disease.

RELEVANCE TO CLINICAL PRACTICE

Collaborative efforts are required by all staff working in general practice to develop models of care to improve screening practices for chronic kidney disease. Future research should focus on interventions that improve collaboration between health care professionals in the primary care setting and public health campaigns to increase awareness of risks of CKD and the importance of screening in the primary care setting.

Evaluation of a chronic kidney disease risk assessment service in community pharmacies

AIM

Targeted 'opportunistic' screening might be a sustainable approach for the early detection of people with undiagnosed chronic kidney disease (CKD). The aim of this study was to implement and evaluate a CKD risk assessment service in the community pharmacy setting.

METHODS

Twenty-four pharmacies in Tasmania, Australia participated in this study. Targeted people were aged between 50 and 74 years, with at least one CKD risk factor. The QKidney risk calculator was used to estimate the participants' 5-year percentage risk of developing moderate-severe CKD. Participants identified with ≥3% risk were referred to their general practitioner (GP) and followed-up after 9 months. Laboratory data was collected from a pathology provider. The main outcome measures were rates of GP referral uptake and of participants who underwent estimated glomerular filtration rate (eGFR) and urine albumin creatinine ratio (ACR) measurement.

RESULTS

We analyzed data for 389 screened participants, of whom 203 (52.1%) had ≥3% 5-year risk of developing moderate-severe CKD and were referred to their GP. Follow-up was successful for 126 participants and showed low (27%) GP referral uptake. Analysis of the pathology data revealed suboptimal kidney testing in participants with ≥3% risk, with eGFR and ACR tests performed for only 52.7% and 25.1% of these participants, respectively.

CONCLUSIONS

There is significant scope for improving early detection of CKD via implementation of a community pharmacy-based CKD risk assessment service. However, a healthcare system that encourages inter-professional collaboration between community pharmacists and GPs, and provides a robust referral pathway is needed to optimize the effectiveness of this service.

Screening and diagnosis of chronic kidney disease in people with type 2 diabetes attending Australian general practice

Australian guidelines recommend annual screening and monitoring of chronic kidney disease (CKD) in people with type 2 diabetes (T2D). A cross-sectional study utilising data from NPS MedicineWise MedicineInsight program from June 2015 to May 2016 was undertaken to explore: (1) the proportion of patients with T2D attending general practice who have had screening for, or ongoing monitoring of, CKD; (2) the proportion of patients without a documented diagnosis of CKD who have pathology consistent with CKD diagnosis; and (3) the patient factors associated with screening and the recording of a diagnosis of CKD. Of 90550 patients with T2D, 44394 (49.0%) were appropriately screened or monitored. There were 8030 (8.9%) patients with a recorded diagnosis of CKD, whereas 6597 (7.3%) patients had no recorded diagnosis of CKD despite pathology consistent with a diagnosis. Older age and diagnosis of hypertension or hyperlipidaemia were associated with increased odds of CKD diagnosis being recorded. Older patients, males, those with recorded diagnoses of hypertension or hyperlipidaemia and those who had their medical record opened more frequently were more likely to be screened appropriately. Screening and monitoring of CKD appears suboptimal. Research to explore barriers to screening, recording and monitoring of CKD, and strategies to address these, is required.

High engagement, high quality: A guiding framework for developing empirically informed asynchronous e-learning programs for health professional educators

E-learning involves the transfer of skills and knowledge via technology so that learners can access meaningful and authentic educational materials. While learner engagement is important, in the context of healthcare education, pedagogy must not be sacrificed for edu-tainment style instructional design. Consequently, health professional educators need to be competent in the use of current web-based educational technologies so that learners are able to access relevant and engaging e-learning materials without restriction. The increasing popularity of asynchronous e-learning programs developed for use outside of formal education institutions has made this need more relevant. In these contexts, educators must balance design and functionality to deliver relevant, cost-effective, sustainable, and accessible programs that overcome scheduling and geographic barriers for learners. This paper presents 10 guiding design principles and their application in the development of an e-learning program for general practice nurses focused on behavior change. Consideration of these principles will assist educators to develop high quality, pedagogically sound, engaging, and interactive e-learning resources.