Interview data
The purposive sample of eight practitioners included six GPs, one pharmacist, and one practice manager. Including the views of a range of staff was important as processes for running the trigger tools varied across practices.
Figure 2 shows the analytic framework17 of themes and subthemes. The following three themes emerged: getting started; trigger tool for safety; trigger tool for learning.
Figure 2. Analytical framework of interview themes and subthemes. CKD = chronic kidney disease. eGFR = estimated glomerular filtration rate.
Getting started
First, the existing trust and working relationship with the CEG11 was seen to be important in getting started with trigger tool implementation.
One GP stated the reason for installing the trigger tool was because of the value that previous CEG interventions had brought:
‘So, I’m more likely to try things out actually because I know there will be some value or some use to it. It’s not going to be just an aimless box-ticking exercise, there is a point to it.’
(GP)
The analysis highlighted key practice elements needed to gain maximum benefit from using the trigger tool.
Good practice organisation, a strong core administrative team, and an existing safety culture were all cited as reasons for getting started:
‘… it works because we’ve got a great administrator called [name], and she just owns the process … I think it’s actually, what appealed to [name] is that she was quite compelled by the safety element of it …’
(GP)
A further driver for implementation and sustainability was the short time it took to review each patient, with one GP saying that the whole process was streamlined and took just 2 to 3 minutes per patient. Another said of current systems:
‘... it [can] involve me writing a form, picking up the phone, sending a message, it’s just it takes time … if you can be of free of the administrative stuff I’ll make better clinical decisions …’
(GP)
One interviewee alluded to barriers affecting the use of the trigger tool, with uncertainty on whether a patient’s eGFR had been adjusted for black ethnicity correction.
Trigger tool for patient safety
Many interviewees cited the importance of the trigger tool acting as a safety net, even though practice systems (such as EMIS Web) have the capability to run graphs of kidney function over time to identify progressive kidney disease:
‘We look at this tool so if there are patients who are likely to decline there is a safety net.’
(GP)
‘I mean clinical governance wise it’s, it feels safe, I’m looking for clinical safety and this gives us clinical safety in this little, particular area.’
(GP)
A change of practice, such as prompting the clinician to undertake a medication review, was evident, with the pharmacist saying that patients were called up for repeat blood tests following review of the trigger, amendments to medications such as metformin, as well as checking that the patient is coded for CKD.
Another important issue raised was a possible change to proactive patient management rather than relying on reactive care. The trigger tool had prompted this interviewee to:
‘… let’s go and have a look at your notes and see what’s happening. That’s really different to how we practise, which tends to be quite on the back foot, so you’re reacting to something all the time. And actually, to do something proactive and really use the record …’
(GP)
Trigger tool for learning (practitioner and practice learning)
Practice staff reflected on an improved degree of confidence in managing CKD:
‘About the importance of a healthy kidney and how to do it. And that, I think that was, for me that was the greatest learning experience really and it’s like it’s diabetes and blood pressure and medication and when we need to refer.’
(GP)
Some felt more at ease in referring or requesting tests:
‘Absolutely. So, I think I’m a lot more confident in requesting things in terms of investigations now.’
(GP)
Some GPs recognised the change in practice as a result of using the tool, with more attention to the patients’ eGFR trajectory:
‘… they’re not looking at eGFR as an isolated thing anymore, they’re very much, when you look at your blood test results you’re just looking at trajectories all the time.’
(GP)
Some interviewees cited the usefulness of the trigger tool to reflect on clinical practice:
‘… if there was anything, so for example that was prescribed that could have caused it? Or whether there was any intercurrent illness?’
(Pharmacist)
The impact of the trigger tool on practice team learning was also evident with interviewees describing ways in which colleagues had acted on recommendations from the CKD lead clinician:
‘So I think this is, this made, I think a big difference for us … if you send a clinician a practice note to remind them of a drop in the eGFR, then to see a few weeks later that they actually had acted upon it …’
(GP)
The impact on working relationships and shared patient care were evident if the patients highlighted by the trigger tools were then discussed in a practice team meeting:
‘So I think that’s a great benefit because you end up talking about it in the clinical meetings and I think, I think it’s stirred up or created greater awareness, I think, amongst us.’
(GP)
Trigger tool reflective data
Reflective data were collated from 3400 completed trigger tools from two CCGs over a 2-year period (January 2016 to December 2017). Generally, these free-text data varied from being very brief to quite detailed, with the latter providing more potential for identifying emerging themes. In a random sample of 1000 records from 79 practices, 92% of reflections were completed, 64% resulted in actions, and 10% resulted in referrals to the virtual CKD secondary care clinic. Table 2 shows the subset of 1921 free-text data extracts categorised by age group and referral status, and stratified by whether the drop in eGFR was >10, >15, or >25 mL/min/1.73 m2.
Table 2. Summary of management actions and referrals recorded in free-text case reflections over 2 years in 79 practices categorised by patient age and stratified by drop in eGFR, N = 1921
Categorisation of the reflection data, by age and referral, enabled the observation of potential variations in clinical management of patients, including the comparison of patients who were younger versus patients who were older.
Both age groups had a referral rate of 8% overall (n = 91 for patients who were younger; n = 70 for patients who were older). Over 50% of all cases in this dataset of younger and older cases had a fall exceeding 15 mL/min/1.73 m2; however, even with eGFR drops of >15 and >25 mL/min/1.73 m2 the referral rates remained similar. Referral rates were also similar between the age groupings regardless of the size of fall in eGFR. In the younger-referred group, reflection data described cases where referral was undertaken for safety:
‘Immediate repeat has been requested but will refer for safety.’
‘SLE nephritis [lupus erythematosus], need to keep renal informed, may just be normal fluctuation, recent MI [myocardial infarction].’
In this group, the most common reflections were about the need for blood pressure and blood sugar control (10/81 cases (data not shown).
In the younger not-referred group there was an emphasis on repeat tests and monitoring; this was often presented as a reason for deferring a decision to refer. Some data describe improvements in eGFR on retesting, suggesting unknown, but transient, reasons for the drop in eGFR:
‘Under review, may refer at later stage if persistent problem.’
‘Repeat blood test showed improvement in renal function.’
In this group, the most common reflections were about control of risk factors, and the fall in eGFR being the first ever drop, with expectation of recovery. The older-referred group highlighted the complexity of managing patients with multimorbidity:
‘Recent significant drop, in line with other health deterioration … advice has been sought from nephrologists to help with further decisions.’
‘Fluctuating eGFR on downward trajectory, likely related to age and diabetes and diuretics being used for CCF [congestive heart failure].’
The most common reflections in this group concerned age-appropriate eGFR decline (7/70 cases (data not shown). The older not-referred group, in common with the younger group, had an emphasis on repeat tests and monitoring:
‘Patient elderly and eGFR repeated and rose again to 66. BP diastolic readings are low, so perfusion may be low. Will repeat again in 1/12 and if remains low then will refer.’
Other reflections recorded a review of the eGFR trajectory over time:
‘Fluctuating eGFR — current value same as 2011. Over 5 years has been as low as 41 and 63 highest value. Referral unlikely helpful at this stage — decision for continued monitoring.’
These recorded actions reflected some of the themes from the interviews, in particular the subthemes of monitoring in the not-referred groups and the trigger tool as safety net in the referred groups.