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. 2023 May 1;18(5):563-572.
doi: 10.2215/CJN.0000000000000136. Epub 2023 Mar 8.

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

Dominic M Taylor  1   2 , Ailish M Nimmo  1   2 , Fergus J Caskey  1   2 , Rachel Johnson  2 , Maria Pippias  1   2 , G J Melendez-Torres  3
Affiliations

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes

Dominic M Taylor et al. Clin J Am Soc Nephrol. .

Abstract

Background: CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes.

Methods: We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work.

Results: Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings.

Conclusions: This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature.

Podcast: This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_05_08_CJN0000000000000136.mp3.

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Figures

None
Graphical abstract
Figure 1
Figure 1
Key components of identified interventions identified in initial scoping review. EPR, electronic patient record; GP, general practitioner.
Figure 2
Figure 2
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing study selection.
Figure 3
Figure 3
Schematic diagram of an integrated model of interventions aiming to improve delivery of evidence-based CKD treatment.
See this image and copyright information in PMC

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References

    1. Jager KJ, Kovesdy C, Langham R, Rosenberg M, Jha V, Zoccali C. A single number for advocacy and communication-worldwide more than 850 million individuals have kidney diseases. Kidney Int. 2019;96(5):1048–1050. doi:10.1016/j.kint.2019.07.012 - DOI - PubMed
    1. Public Health England. Chronic Kidney Disease Prevalence Model, London, Public Health England Publications, 2014.
    1. Astor BC Matsushita K Gansevoort RT, et al. . Lower estimated glomerular filtration rate and higher albuminuria are associated with mortality and end-stage renal disease. A collaborative meta-analysis of kidney disease population cohorts. Kidney Int. 2011;79(12):1331–1340. doi:10.1038/ki.2010.550 - DOI - PMC - PubMed
    1. Matsushita K van der Velde M Astor BC, et al. . Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073–2081. doi:10.1016/s0140-6736(10)60674-5 - DOI - PMC - PubMed
    1. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu C-Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351(13):1296–1305. doi:10.1056/NEJMoa041031 - DOI - PubMed

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