Getting the most out of remote care: Co-developing a Toolkit to improve the delivery of remote kidney care appointments for underserved groups.

BACKGROUND: Telephone and video appointments are still common post-pandemic, with an estimated 25%-50% of kidney appointments in the United Kingdom still conducted remotely. This is important as remote consultations may exacerbate pre-existing inequalities in those from underserved groups. Those from underserved groups are often not represented in health research and include those with learning disability, mental health needs, hearing/sight problems, young/older people, those from ethnic minority groups. OBJECTIVES: The aim was to develop a Toolkit to improve the quality of remote kidney care appointments for people from different underserved groups. DESIGN: A parallel mixed methods approach with semistructured interviews/focus groups and survey. We also conducted workshops to develop and validate the Toolkit. PARTICIPANTS: Seventy-five renal staff members completed the survey and 21 patients participated in the interviews and focus groups. Patients (n = 11) and staff (n = 10) took part in the Toolkit development workshop, and patients (n = 13) took part in the Toolkit validation workshop. RESULTS: Four themes from interviews/focus groups suggested areas in which remote appointments could be improved. Themes were quality of appointment, patient empowerment, patient-practitioner relationship and unique needs for underserved groups. Staff reported difficulty building rapport, confidentiality issues, confidence about diagnosis/advice given, technical difficulties and shared decision making. CONCLUSION: This study is the first to explore experiences of remote appointments among both staff and those from underserved groups living with kidney disease in the United Kingdom. While remote appointments can be beneficial, our findings indicate that remote consultations need optimisation to meet the needs of patients. The project findings informed the development of a Toolkit which will be widely promoted and accessible in the United Kingdom during 2024.

Novel point-of-care cytokine biomarker lateral flow test for the screening for sexually transmitted infections and bacterial vaginosis: study protocol of a multicentre multidisciplinary prospective observational clinical study to evaluate the performance and feasibility of the Genital InFlammation Test (GIFT).

INTRODUCTION: A prototype lateral flow device detecting cytokine biomarkers interleukin (IL)-1α and IL-1ß has been developed as a point-of-care test-called the Genital InFlammation Test (GIFT)-for detecting genital inflammation associated with sexually transmitted infections (STIs) and/or bacterial vaginosis (BV) in women. In this paper, we describe the rationale and design for studies that will be conducted in South Africa, Zimbabwe and Madagascar to evaluate the performance of GIFT and how it could be integrated into routine care. METHODS AND ANALYSIS: We will conduct a prospective, multidisciplinary, multicentre, cross-sectional and observational clinical study comprising two distinct components: a biomedical ('diagnostic study') and a qualitative, modelling and economic ('an integration into care study') part. The diagnostic study aims to evaluate GIFT's performance in identifying asymptomatic women with discharge-causing STIs (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) and Mycoplasma genitalium (MG)) and BV. Study participants will be recruited from women attending research sites and family planning services. Several vaginal swabs will be collected for the evaluation of cytokine concentrations (ELISA), STIs (nucleic acid amplification tests), BV (Nugent score) and vaginal microbiome characteristics (16S rRNA gene sequencing). The first collected vaginal swab will be used for the GIFT assay which will be performed in parallel by a healthcare worker in the clinic near the participant, and by a technician in the laboratory. The integration into care study aims to explore how GIFT could be integrated into routine care. Four activities will be conducted: user experiences and/or perceptions of the GIFT device involving qualitative focus group discussions and in-depth interviews with key stakeholders; discrete choice experiments; development of a decision tree classification algorithm; and economic evaluation of defined management algorithms. ETHICS AND DISSEMINATION: Findings will be reported to participants, collaborators and local government for the three sites, presented at national and international conferences, and disseminated in peer-reviewed publications.The protocol and all study documents such as informed consent forms were reviewed and approved by the University of Cape Town Human Research Ethics Committee (HREC reference 366/2022), Medical Research Council of Zimbabwe (MRCZ/A/2966), Comité d'Ethique pour la Recherche Biomédicale de Madagascar (N° 143 MNSAP/SG/AMM/CERBM) and the London School of Hygiene and Tropical Medicine ethics committee (LSHTM reference 28046).Before the start, this study was submitted to the Clinicaltrials.gov public registry (NCT05723484). TRIAL REGISTRATION NUMBER: NCT05723484.

A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy.

Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended.

Healthcare professional education in shared decision making in the context of chronic kidney disease: a scoping review.

RATIONALE & OBJECTIVE: Shared decision making (SDM) is a collaborative effort between healthcare professionals, individuals with CKD whereby clinical evidence, expected outcomes and potential side-effects are balanced with individual values and beliefs to provide the best mutually decided treatment option. Meaningful SDM is supported by effective training and education. We aimed to identify the available evidence on SDM training and education of healthcare professionals caring for people with chronic kidney disease. We aimed to identify existing training programs and to explore what means are used to evaluate the quality and effectiveness of these educational efforts. METHODOLOGY: We performed a scoping review to study the effectiveness of training or education about shared decision making of healthcare professionals treating patients with kidney disease. EMBASE, MEDLINE, CINAHL and APA PsycInfo were searched. RESULTS: After screening of 1190 articles, 24 articles were included for analysis, of which 20 were suitable for quality appraisal. These included 2 systematic reviews, 1 cohort study, 7 qualitative studies, and 10 studies using mixed methods. Study quality was varied with high quality (n = 5), medium quality (n = 12), and low quality (n = 3) studies. The majority of studies (n = 11) explored SDM education for nurses, and physicians (n = 11). Other HCP profiles included social workers (n = 6), dieticians (n = 4), and technicians (n = 2). Topics included education on SDM in withholding of dialysis, modality choice, patient engagement, and end-of-life decisions. LIMITATIONS: We observed significant heterogeneity in study design and varied quality of the data. As the literature search is restricted to evidence published between January 2000 and March 2021, relevant literature outside of this time window has not been taken into account. CONCLUSIONS: Evidence on training and education of SDM for healthcare professionals taking care of patients with CKD is limited. Curricula are not standardized, and educational and training materials do not belong to the public domain. The extent to which interventions have improved the process of shared-decision making is tested mostly by pre-post testing of healthcare professionals, whereas the impact from the patient perspective for the most part remains untested.

"You Can Change the World With a Haircut": Evaluating the Feasibility of a Barber-led Intervention for Men of Black and Ethnic Minority Heritage to Manage High Blood Pressure.

BACKGROUND: People of Black, Asian and minority ethnic (BAME) heritage have a higher-than-average incidence of, and mortality from hypertension and stroke. Therefore, it is important to identify new settings for engaging people at risk of high blood pressure (BP). AIM: This feasibility study aimed to evaluate if barbers in a London borough can support and educate men of BAME heritage to manage their BP. Following UK Medical Research Council guidance, the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework was used to guide study objectives and feasibility outcomes. METHODS: We collaborated with 8 barbers who were part of an existing BAME barber network. Barbers were trained online (1.5 h) and face-to-face (3 h) to provide BP healthcare advice and take customers BP readings. Qualitative field notes were collected to assess how best to recruit and train barbers, and to understand how to maintain motivation and retention of barbers. BP readings were recorded between June 2021 and March 2022. RESULTS: Both online and face-to-face training were effective, however, greater focus on how to start conversations about BP with clients was needed. We found that motivation, incentivization and regular contact with barbers were important for recruitment, retention, and sustained BP measurement. Obtaining BP readings was challenging due to client concerns about recording their data and the impracticalities of recording results. We captured 236 BP recordings, of which 39 (16.53%) were over 140/90 mmHg; of these, 5 were over 180/100 mmHg. CONCLUSION: The combined data showed that educating barbers to take BP readings and deliver healthcare advice about BP is a viable intervention for rollout in a large-scale study. It has demonstrated the need to identify strategies to motivate barbers for sustained recruitment and retention, as well as further efforts to build trust among customers for long-term BP surveillance.

Overcoming the challenges of recruiting and interviewing patients following critical illness.

BACKGROUND: The strict restrictions implemented in England during the COVID-19 pandemic meant it was no longer possible to recruit or interview participants in person. However, virtual recruitment and interviews are not without their challenges, particularly when exploring sensitive topics. AIM: To discuss how to overcome some of the challenges involved in recruiting and interviewing participants who have been critically ill with COVID-19. DISCUSSION: An exploratory, descriptive study was conducted involving interviews with 20 people who had been critically ill with COVID-19 and had been discharged from two community-based healthcare settings in London, England. Participants were interviewed at home after being discharged from hospital after at least one month. The sensitivity of the research topic meant strategies for recruiting and interviewing needed to be adapted, including involving patient experience facilitators, using virtual interviews, managing the distress of participants and self-care for the researchers. CONCLUSION: The adaptations used in this study can be used in research involving people who have been critically ill. IMPLICATIONS FOR PRACTICE: Researchers can explore innovative ways to recruit participants using hospital or community staff who are not usually involved in research. Virtual interviews require additional skills, such as building rapport with participants, so may require additional training. A distress protocol for participants should always be considered when discussing sensitive topics. Self-care and debrief strategies for interviewers are also critical.

Evaluating the feasibility and acceptability of home-based urinalysis for albumin-creatinine ratio with smartphone technology: A quality improvement project.

BACKGROUND: Despite albumin-creatinine ratio (urine) testing being recommended for detection of chronic kidney disease among adults with diabetes, testing rates are suboptimal. AIM: We implemented and evaluated a quality improvement project in an inner-city diabetes population in London, UK to assess the feasibility and acceptability of implementing novel home-based urinalysis using smartphone technology. METHODS: After eligible patients were identified and consented, testing kits were sent to the patient's home. Test results and patient feedback were collected through the smartphone application. Focus group discussions were conducted to evaluate primary care staff perspectives on uptake and delivery of the service. RESULTS: In total 2370 patients agreed to take part. Of these, 1244 completed the test (61% of those eligible) and of these, 465 (37%) had clinically significant albuminuria. 98% of patients found the test easy or very easy to use. Staff in primary care found the service to be beneficial for patients, and reported ease of set up and minimal administrative processes. Concerns regarding barriers among patients with lower digital literacy and non-English speakers were raised although these concerns were not substantiated. CONCLUSION: Home-based albumin-creatinine ratio urine testing may improve the testing rates of people with diabetes at higher risk of chronic kidney disease. This is important post-pandemic, as healthcare services are trying to return to pre-pandemic levels of care. The study also found that the use of smartphone technology in an underserved (deprived) community is feasible, despite reservations about levels of digital literacy and possible language barriers. Further evaluation of effectiveness and costs is required.

Patients' perspectives of recovery after COVID-19 critical illness: An interview study.

BACKGROUND: Critical illness is a traumatic experience, often resulting in post-intensive care syndrome, affecting people's physical, psychological, emotional, and social well-being. The early recovery period is associated with increased risk, negatively impacting longer-term outcomes. AIMS: The aims of this study were to understand the recovery and rehabilitation needs of people who survive a COVID-19 critical illness. STUDY DESIGN: An exploratory descriptive qualitative interview study with 20 survivors of COVID-19 critical illness from two community-based healthcare settings in London, England. Data collection took place September 2020-April 2021, at least 1 month after hospital discharge by telephone or virtual platform. Data were subjected to inductive thematic analysis and mapped deductively to the three core concepts of self-determination theory: autonomy, competence and relatedness. RESULTS: Three key themes emerged: traumatic experience, human connection and navigating a complex system. Participants described how societal restrictions, fear and communication problems caused by the pandemic added to their trauma and the challenge of recovery. The importance of positive human connections, timely information and support to navigate the system was emphasized. CONCLUSIONS: Whilst findings to some extent mirror those of other qualitative pre-pandemic studies, our findings highlight how the uncertainty and instability caused by the pandemic add to the challenge of recovery affecting all core concepts of self-determination (autonomy, competence, relatedness). RELEVANCE TO CLINICAL PRACTICE: Understanding survivors' perspectives of rehabilitation needs following COVID-19 critical illness is vital to delivery of safe, high-quality care. To optimize chances of effective recovery, survivors desire a specialist, co-ordinated and personalized recovery pathway, which reflects humanized care. This should be considered when planning future service provisions.

Gender Differences in Experiences and Expectations of Hemodialysis in a Frail and Seriously Unwell Patient Population.

Introduction: Surprisingly few studies have explored the experiences of seriously unwell people with kidney disease on hemodialysis therapy: we conducted a mixed-methods study to investigate gender differences in illness experience, symptom burden, treatment considerations or expectations in this cohort. Methods: Seriously unwell people on hemodialysis (1-year mortality risk of >20%) at 3 hospital-based units were invited to take part in a structured interview or to complete the same questions independently via a questionnaire. A total of 54 people took part (36 males, 18 females); data analysis was undertaken using a thematic approach. Results: "Desire to keep living" is the most important and basic thought process when starting dialysis. Fear also predominates influencing risk assessment and decision-making. Once fear is managed, there are physical, social, practical and emotional issues to rationalize, but choice only seems possible if shared decision-making is part of the consultation.Gender differences were seen in perceived hopes and expectations of treatment. Males were more likely to prioritize achievement of physical goals, with females prioritizing a wish to feel well. Both genders reported significantly higher symptom scores than their health care provider perceived, however this difference was more marked in females. Dialysis regret existed in >50% of participants and 6 out of 54 (11%) stated that they would have chosen no dialysis at all. Females were more likely to report feeling depressed (P = 0.001). Conclusion: Different genders approach treatment decisions and prioritize treatment expectations differently. Recognizing this will allow personalized care plans to be developed and improve the experiences of seriously unwell people with kidney disease.

Changes in North Atlantic deep-water oxygenation across the Middle Pleistocene Transition.

The oxygen concentrations of oceanic deep-water and atmospheric carbon dioxide (pCO2) are intrinsically linked through organic carbon remineralization and storage as dissolved inorganic carbon in the deep sea. We present a high-resolution reconstruction of relative changes in oxygen concentration in the deep North Atlantic for the past 1.5 million years using the carbon isotope gradient between epifaunal and infaunal benthic foraminifera species as a proxy for paleo-oxygen. We report a significant (>40 micromole per kilogram) reduction in glacial Atlantic deep-water oxygenation at ~960 thousand to 900 thousand years ago that coincided with increased continental ice volume and a major change in ocean thermohaline circulation. Paleo-oxygen results support a scenario of decreasing deep-water oxygen concentrations, increased respired carbon storage, and a reduction in glacial pCO2 across the Middle Pleistocene Transition.

Prevalence of frailty and cognitive impairment in older transplant candidates - a preview to the Kidney Transplantation in Older People (KTOP): impact of frailty on outcomes study.

BACKGROUND: Kidney transplantation in older people has increased, however older transplant recipients experience mixed outcomes that invariably impacts on their quality of life. The increased vulnerability of older end stage kidney disease patients to frailty and cognitive impairment, may partially explain the differences in outcomes observed. The Kidney Transplantation in Older People (KTOP): impact of frailty on clinical outcomes study is an active clinical study aiming to explore the experience of older people waiting for and undergoing transplantation. In this manuscript we present the study protocol, the study cohort, and the prevalence of frailty and cognitive impairment identified at recruitment. METHODS: The KTOP study is a single centre, prospective, mixed methods, observational study. Recruitment began in October 2019. All patients aged 60 or above either active on the deceased donor waitlist or undergoing live donor transplantation were eligible for recruitment. Recruited participants completed a series of questionnaires assessing frailty, cognition, and quality of life, which are repeated at defined time points whilst on the waitlist and post-transplant. Clinical data was concurrently collected. Any participants identified as frail or vulnerable were also eligible for enrolment into the qualitative sub-study. RESULTS: Two hundred eight participants have been recruited (age 60-78). Baseline Montreal Cognitive Assessments were available for 173 participants, with 63 (36.4%) participants identified as having scores below normal (score < 26). Edmonton Frail Scale assessments were available for 184 participants, with 29 participants (15.8%) identified as frail (score ≥ 8), and a further 37 participants (20.1%) identified as being vulnerable (score 6-7). CONCLUSION: In the KTOP study cohort we have identified a prevalence of 36.4% of participants with MoCA scores suggestive of cognitive impairment, and a prevalence of frailty of 15.8% at recruitment. A further 20.1% were vulnerable. As formal testing for cognition and frailty is not routinely incorporated into the work up of older people across many units, the presence and significance of these conditions is likely not known. Ultimately the KTOP study will report on how these parameters evolve over time and following a transplant, and describe their impact on quality of life and clinical outcomes.

Patient perspectives and experiences of remote consultations in people receiving kidney care: A scoping review.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid and sometimes chaotic change in how clinical care was delivered for people living with kidney disease, with increased reliance on digital technologies and the introduction of remote services. OBJECTIVES: To conduct a scoping review of studies about patients' experiences and perspectives in receipt of remote consultations for kidney care. DESIGN: Using Arksey and O'Malley's framework, three databases were searched on EBSCO (CINAHL, MEDLINE and Psych INFO). The search included studies published in English from August 2010 to August 2021. RESULTS: Eight studies met the scoping review criteria (two cross-sectional, two mixed-method and four qualitative). Five themes were identified: overall satisfaction with remote services, benefits to patients (convenience, involvement in care and patient safety), barriers to remote consultations (technical difficulties, digital literacy and loss of interpersonal communication), patient concerns (need for physical examination, privacy and confidentiality) and prerequisites for successful remote care (existing patient-practitioner relationship, stable illness phase and access to technology). CONCLUSION: Remote consultations confer multiple advantages to patients; therefore, remote consultations should be offered as an option to patients living with kidney disease beyond the COVID-19 pandemic. However, there are several barriers to remote consultation that need to be addressed and understood before implementing remote care long-term. Future research should examine the impact of remote consultations on people living with kidney disease from under-served groups to identify barriers and ensure their suitability and accessibility to the wider population for a more patient-centred approach to kidney care.

Patient activation and its association with symptom burden and quality of life across the spectrum of chronic kidney disease stages in England.

BACKGROUND: The knowledge, skills, and confidence to manage one's own health is termed patient activation and can be assessed using the Patient Activation Measure (PAM). This measure is increasingly recommended for use in chronic kidney disease (CKD), but there is a need to better understand patient activation within this population. This work aimed to explore the association of PAM with patient-reported outcomes, namely symptom burden and health-related quality of life (HRQoL), to understand the relationship between patient activation and outcomes which are of importance to people with CKD. METHODS: Non-dialysis, dialysis, and kidney transplant patients from 14 renal units across England completed a survey comprising questionnaires assessing patient activation, symptom burden, and HRQoL. Latent class analysis (LCA) was used to determine HRQoL and symptom burden subgroups in the data. Multinomial logistic regression analyses were performed to investigate the associations between patient activation and symptom burden and HRQoL classes separately, adjusting for age, gender, ethnicity, deprivation and treatment modality. RESULTS: Three thousand thirteen participants (mean age 61.5 years, 61.8% males, and 47% haemodialysis) were included in the analysis. Patient activation was strongly associated with both the HRQoL and symptom burden classes identified, with highly activated patients more likely to report higher HRQoL (P = < 0.0001; OR 29.2, 95% CI 19.5-43.9) and fewer symptoms (P = < 0.0001; OR 25.9, 95% CI 16.8-40.2). CONCLUSION: Lower activation levels are associated with a higher symptom burden and reduced HRQoL across the trajectory of CKD stages and treatment modalities. Therefore, targeted and holistic self-management support focussing on improving activation may have the potential to improve aspects of health experience which are valued by individuals living with kidney disease.

Decision-making experiences of young adults with long-term conditions.

BACKGROUND: Young adults with long-term conditions can struggle to accept their diagnosis and can become overwhelmed with managing their condition. Suboptimal transfer from paediatric to adult services with a resultant disengagement with the service can result in less involvement in care and decision-making. Shared decision-making can improve involvement in health decisions and increase satisfaction with treatment/therapy and care. OBJECTIVES: An integrative literature review was conducted to explore and understand young adults' experiences of decision-making in health care. DESIGN: An integrative literature review. DATA SOURCES: CINAHL, EMCARE, PsycINFO, HMIC, EMBASE, Web of Science, PubMed, MEDLINE, EBSCOHOST and COCHRANE databases were searched for relevant literature published between January 1999 and January 2020. FINDINGS: Thirteen primary research papers met the inclusion criteria. Four main themes were identified: (1) Information delivery and communication; (2) participation in decision-making; (3) social factors influencing decision-making and (4) emotional impact of decision-making. CONCLUSIONS: Young adults with long-term conditions have specific decision-making needs which can impact their emotional health. Research with a specific focus on young adults' experiences of decision-making in health care is needed.

Barriers and facilitators to implementing and sustaining peer support in kidney care.

INTRODUCTION: Peer support offers informational, appraisal and emotional support for people with kidney disease, is recommended in national policy, yet has low engagement levels. This paper reports results of a national survey and qualitative interviews in the UK with the aim of increasing understanding of peer support availability and its barriers and facilitators. LITERATURE REVIEW: A recent narrative review highlighted the barriers and facilitators to peer support uptake among people with kidney disease however called on further studies to be conducted. MATERIAL AND METHODS: The survey, adapted from a 2012 version, was sent to all 83 UK kidney units. Semistructured interviews were conducted with staff, recipients and supporters from two units. RESULTS: Forty-four units completed the survey, and 10 staff, 7 patients and 2 peer supporters were interviewed. The most common facilitators were promotion with staff and having peer support champions. Barriers included lack of staff time, guidance/information, other projects taking priority and too few supporters. DISCUSSION: Little progress has been made since 2012; a proportion of units without peer support remains significant, with similar barriers identified in 2020. Services could be designed to limit the time needed for their creation and maintenance through having simpler referrals and designating staff liaisons. IMPLICATIONS FOR CLINICAL PRACTICE: Peer support programmes should have passionate staff and volunteers, involve recipients in the design, recruit an array of supporters and establish evaluations to determine the progress/outcomes. A resource toolkit was developed in response to this project. CONCLUSION: Findings from the national survey and qualitative interviews showed that more peer support optimisation and prioritisation is needed to ensure benefits are maximised.

A narrative review of peer support barriers and facilitators in kidney care.

INTRODUCTION: Patients with chronic kidney disease often experience emotional/mental challenges and benefit from peer support, as it provides insight/information from others with the same condition. Previous studies show it is effective in improving health outcomes and aids in treatment decisions. LITERATURE REVIEW: There is low peer support uptake among patients with chronic kidney disease in the United Kingdom and staff do not utilise peer support services fully. Few studies within the United Kingdom have focused on peer support barriers/facilitators, so this narrative review aimed to understand them from staff and patient perspectives. MATERIALS AND METHODS: A comprehensive search strategy and inclusion/exclusion criteria were applied with a two-step process of article selection employed using two reviewers. Thematic analysis was applied. RESULTS: Five articles were included and six themes emerged. Low referrals and difficulty matching were staff barriers; concern regarding the relationship dynamic and the format/delivery were patient barriers. Promotion of the service aided the uptake from staff, while patients valued inclusivity. DISCUSSION: Increased promotion of peer support benefits through training/awareness may improve staff referrals and there should be greater exposure nationally. A flexible format is essential to ensure ample opportunity for access. CONCLUSION: This review highlights the current literature on peer support barriers/facilitators. Further study is needed to evidence which approaches best overcome staff- and patient-barriers.

Quality improvement at scale: evaluation of the drivers and barriers to adoption and sustainability of an intervention to reduce late referral in chronic kidney disease.

This quality improvement project aimed to drive large scale and sustained change to reduce the burden of chronic kidney disease in the UK. The intervention is a software program that extracts relevant biochemical data from laboratory databases which then generate graphs of estimated kidney function (eGFR) over time. Graphs showing progressive kidney disease are sent directly back to general practitioners (GPs) to alert them to rereview patient care and if necessary, refer to renal services. The aim of this evaluation study was to explain the barriers and drivers to implementation and adoption of the eGFR graph intervention. This evaluation study involved 5 of the 20 participating renal units (sites) . A developmental evaluation approach was used. Methods included collection of descriptive data about graph reporting; GP surveys (n=68); focus groups (n=4) with practices; face-to-face interviews with secondary care clinicians (n=10). Results showed the mean number of graphs reviewed per week per site was 230, taking 1 hour per week per site. Only 18.2% graphs highlighted a concerning decline in kidney function. Important enablers to sustain the intervention were low cost, easy to understand, a sense of local ownership and perceived impact. Barriers included nephrologists' perceived increase in new referrals. We concluded that developmental evaluation can explain the barriers/drivers to implementation of a national quality improvement project that involves a variety of different stakeholders. The intervention has the potential to slow down progression of kidney disease due to the eGFR prompts alerting GPs to review the patient record and take action, such as reviewing medications and referring to renal teams if progressive kidney disease had not been identified previously.

Getting the Balance Right: Medical Futility, Scientific Advancement, and the Role of Law.

The concept of medical futility as an applied ethical framework has seen a rise and fall in its popularity over the last 30 years. It is a term used in relation to the assessment of a patient's health condition that is deemed untreatable, irreversible, and unresolvable. In four recent cases, Gard, Evans, Haastrup, and Raqeeb, the concept has been brought to the fore once again. These cases highlight a mounting tension between clinicians and families. Parental desires to see their child's treatment continued, while understandable, should not dominate treatment planning. This article analyses judicial interpretation of the factors which determine an assessment of futility and in doing so, argues that the role of medical futility in judicial decisions of this kind is gaining prominence and will continue to do so as scientific advancement blurs the limits of medicine even further.