Identifying interventions to optimise advanced kidney care services: scoping review protocol
Identifying interventions to optimise advanced kidney care services: scoping review protocol
Multidisciplinary advanced kidney care (AKC) services provide care to patients with advanced chronic kidney disease (CKD) (typically estimated glomerular filtration rate (eGFR) ≤20 mls/min/1.73m2), as symptoms and complications become more common, also in preparation for kidney failure treatments. Despite their prominence in UK renal services, there is no consensus around the best practice for AKC services in terms of care delivery models or interventions to optimise patient care, and there is widespread geographical variation in practice. The UK Kidney Association Kidney Quality Improvement Partnership has launched a 3-year ‘Transform AKC’ quality improvement project to address unmet needs in AKC services and work towards improvement. This scoping review is part of the Transform AKC project and aims to identify existing evidence for the current and best practice in AKC. The aim of this review is to establish any evidence that demonstrates best practice models of care and interventions to optimise care for adult patients with advanced CKD.
We will undertake a scoping review seeking to identify and evaluate evidence that demonstrated best practice for care of adults with advanced CKD. Databases (Medline and Embase) will be searched systematically (search dates from 1 January 2014 to 8 August 2024), and a final list of included studies will be analysed and synthesised.
We will use robust methodology to identify the existing literature describing the best practices in care of adults with advanced CKD. These findings will directly inform the ‘Transform AKC’ national quality improvement project, in which this scoping review is embedded. Findings will also be disseminated through national conferences and will be published in a relevant journal.
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Access to multidisciplinary advanced kidney care (AKC) services for patients with progressive chronic kidney disease (CKD) 4–5 is recommended by the UK Renal National Service Specification. AKC services are progressively replacing previous ‘low clearance’ or ‘predialysis’ clinics.1 A core component of AKC is the multidisciplinary team (MDT) input (including specialist nurses, nephrologists, dietitians, social workers, psychologists, vascular access surgeons or co-ordinators, pharmacists, occupational therapists, physiotherapists, geriatricians and transplant work-up specialists).
AKC services are designed for patients with advanced CKD who may be approaching end-stage kidney disease. The threshold for entry to AKC is in keeping with National Institute for Health and Care Excellence (NICE) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines,2 3 but there is variation in practice. Approaches include a threshold eGFR (typically eGFR 15–20), rate of eGFR decline or risk prediction models such as the kidney failure risk equation (KFRE).4 The ideal threshold KFRE for entry to AKC has not yet been determined and may depend on local factors.
AKC services are well established in many parts of the UK, but there is variation between kidney units in the delivery of care, including the breadth and training of the AKC renal MDT and whether the service meets the needs of the local population. Comprehensive guidance on best practice has not yet been established. There is limited guidance on details of patient assessment (including cognition, health literacy, functional ability, frailty and psychosocial issues); symptom detection and management; discussion of patients’ priorities; education for patients and carers; and impact of treatment choices on quality and length of life. There is a lack of data to measure the entry and progress of patients through AKC, including the key milestones of receiving education on treatment choices, listing for transplant and choosing a future dialysis modality. There is variation in practice in the care of patients with failing transplants, some of whom remain under transplant clinics and some of whom transfer to AKC services. There is also a need to measure the experience of patients receiving AKC to guide future improvement. A previous scoping review into multidisciplinary CKD clinic practices identified significant heterogeneity in team composition, entry criteria, follow-up and processes as well as inadequate reporting of clinic structure and function,5 but this review was not focused on advanced CKD or AKC.
The UK Kidney Association (UKKA) Kidney Quality Improvement Partnership (KQIP) has commenced a 3-year programme ‘Transform AKC’ in partnership with Kidney Care UK. This project aims to work closely with renal multidisciplinary professionals, patients and carers to address unmet needs in AKC. The focus in year one will be on understanding the current situation from the perspectives of key stakeholders before moving into subsequent years, where kidney units will use quality improvement methodology to test changes in practice and measure the impact. Staff training to embed changes in practice will be delivered during the third year. This scoping review is part of the Transform AKC project and aims to identify existing evidence for current and best practice in AKC. This will allow the development of interventions to improve AKC services nationally.
The aim of this review is to identify evidence that demonstrates best practice models of care and interventions to optimise care for adult patients with advanced CKD.
This scoping review will follow Arksey and O’Malley’s five-staged approach, described in detail below.6 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines and checklist will be used to ensure a systematic approach; the checklist will be included on publication of the completed review as an appendix.7 Emphasis on clarity of concept, population of interest and outcomes will be used to ensure the search strategy is focused.8 9 The study is planned to run from 1 June 2024 to 1 June 2025.
The aim, as stated above, is to identify evidence that describes or demonstrates ‘best practice’ for multidisciplinary care in the AKC clinic. We have identified the following broad research questions:
The research questions may be iteratively narrowed as the review progresses, in keeping with typical scoping review methodology.
Inclusion criteria
Population
Adults>18 years and not receiving dialysis, with advanced CKD stage 4–5 and/or eGFR<20 and/or KFRE>20% at 2 years (or equivalent), (including those with failing kidney transplant).
Studies
All study designs (including systematic reviews, interventional studies and qualitative research) will be considered. The focus is on best practice and interventions, so purely descriptive and observational studies will not be included.
Interventions
Interventions which could be implemented by members of a MDT will be included, but specific pharmaceutical interventions for individual symptoms (other than in the context of guidelines for symptom management) will not be considered.
Context
Outpatient kidney services, AKC clinic, inpatient kidney services focused on relevant patient group and integrated services between primary and secondary/tertiary care. Studies relevant to the UK healthcare system.
Outcomes
Quality of shared decision-making, rates of home therapy utilisation, pre-emptive transplant listing, access to kidney transplantation, definitive incident dialysis access, access to conservative kidney management, involvement of MDT members, quality of life, patient experience, symptom burden, survival, advanced care planning, hospitalisation rate, and patient and carer satisfaction with treatment option.
Exclusion criteria
Studies focusing on the general CKD population where subgroup analysis (to CKD 4/5 and/or advanced CKD) is not possible.
Studies not published in the English language and studies published prior to 2014 (due to cost and time restraints); these key limitations will be acknowledged when the study is reported.
Studies focusing on paediatric populations.
Studies from healthcare contexts such that interventions will not be relevant or transferable to the UK healthcare setting.
Literature searches
A comprehensive and iterative approach to identify evidence meeting the above criteria will be performed. The search will be conducted by the two health information specialists (KS and RS) within the team. A pragmatic approach will be used with regular meetings among the team to meet deadlines and use available resources. The search dates will be from 1 January 2014 to 8 August 2024.
Resources searched
Box 1 lists the two databases to be searched, which contain published peer-review literature; a limited list will be used because of time restraints, and because it is anticipated, the key literature will be identified in these mainstream databases. Grey literature will not be specifically searched for but may later be identified in the final stage (see below). Searches will be conducted in three phases. First, scoping to gauge the volume and develop/refine the protocol. Second, more comprehensive searches will be conducted using search terms outlined in box 2. The final stage will be confirming, and this is to identify other sources of information such as grey literature which may be identified through searching reference lists of identified papers. The extent of this will be decided within the team at the sifting stage, including identifying any relevant policies and guidelines that need to be reviewed.
Box 1
Databases
Ovid Medline; Embase
Box 2
Ovid MEDLINE(R) ALL<1946 to August 07, 2024>
exp *Renal Insufficiency, Chronic/ OR (chronic kidney disease OR CKD).ab,ti. OR *Kidney Failure, Chronic/ OR (chronic renal failure OR chronic kidney failure OR chronic renal disease).ab,ti. OR end stage kidney.ab,ti. OR end stage renal.ab,ti. OR established kidney disease.ab,ti. OR chronic renal insufficiency.ab,ti. OR late-stage kidney disease.ab,ti. OR (predialysis OR pre-dialysis).ab,ti.
AND
((interdisciplinary OR inter-disciplinary OR multidisciplinary OR pre-dialysis OR multi-disciplinary OR coordinat* OR co-ordinat* OR MDT OR interprofessional OR multiprofessional OR augment* OR functional OR integrated) adj2 (care OR patient OR program OR communicat* OR team OR initiative OR assessment OR monitor* OR support*)).ab,ti. OR (quality adj life).ab,ti. OR exp “Quality of Life”/OR improv* outcome*.ab,ti. OR (decision aid* OR informed decision).ab,ti. OR Patient Reported Outcome Measures/ OR Decision Making, Shared/
NOT
*Kidney Transplantation/ OR kidney transplantation.kw. OR “haemodialysis”.kw. OR “hemodialysis”.kw. OR*Renal Dialysis/ OR *“Anemia”/ OR anaemia.kw. OR anemia.kw. OR *“Blood Pressure”/ OR “blood pressure”.kw. OR *“Chronic Kidney Disease-Mineral and Bone Disorder”/ OR “mineral bone disorder”.kw. OR exp *Diabetes Mellitus/ OR “Diabetes”.kw.
Terms were searched either as a medical subject heading (indicated by /), title and abstract (indicated by .ab,ti.) or keyword (indicated by .kw.).
Search terms (thesaurus and free text)
The search terms will be identified by initially testing in one database and discussing among the team. The search will be wide enough to encompass the full range of potential perspectives of AKC services and models of care. A test set of relevant papers will be identified prior to the formal literature search, and the literature search will be tested to ensure it picks up the complete test set of papers (to ensure the search is sufficiently broad).
Process of searching
The searches will be undertaken by two health information specialists (KS and RS) and uploaded to Covidence (a web-based software platform for systematic reviews) to enable sharing across the team. This will provide a robust process of tracking and transparency.
Once the material located in the search stage has been uploaded to Covidence, the reviewing team members (RK, HL, OS, HH and RD) will filter papers using the inclusion and exclusion criteria. Because of the broad search strategy and anticipated large number of studies, the initial sift will use the study title only to remove studies clearly not relevant (such as animal studies and those clearly unrelated to kidney disease); all reviewing team members will be involved in this process to ensure consistency. The next sift will be based on title and abstract and will also involve all reviewing team members; each article will be screened by two reviewers. The third stage will be a full text review, which will be conducted by the whole team to create the final list of included studies. Consideration will be made collectively on the inclusion of abstracts if full text is not available. A rapid review assessment tool will be developed using the inclusion criteria as guidance. The team will be involved at all stages to increase validity and provide a clear audit trail of decisions made, and these will be recorded in meetings and within Covidence software. Any disagreement regarding potential included studies will be discussed openly within the team, with the senior members (HH and RD) having casting votes.
The data will be extracted in a table form into Excel spreadsheets, providing an overview and map of the evidence. Headings will include the following (not exhaustive):
Intervention.
Outcomes.
Study design.
Key findings.
Quality assessments are not typically required in scoping reviews; however, once the included studies have been agreed, the team will make decisions based on study design if quality assessment is indicated.
Data will be summarised and analysed descriptively. Study characteristics will be presented in a table format. The approach to reporting the evidence will be a narrative format using the aims of the review as guidance. The scoping review process is iterative, and the collation, summarising and reporting of the results will depend on the nature of the included studies and the results identified.
The key purpose of the scoping review is to guide the Transform AKC KQIP project by identifying gold standards and best practice in AKC that can be adopted and tested through quality improvement methodology. The findings of the scoping review will therefore be fed back directly, in detail, to the Transform AKC project board and stakeholders, as well as being written up for publication and general dissemination.
Individual-level data on research participants will not be collected or held by the review team, nor will other sensitive or confidential data, so there is no specific data protection policy.
The Transform AKC project involves patients at all stages, including focus groups to determine the best practice and current gaps in service provision. This has highlighted a lack of standardised models to provide high-quality AKC and the need for a scoping review to summarise published evidence. Patient involvement has therefore been embedded within the scoping review from its conception. Opportunities to discuss the results of the scoping review with patients, carers and healthcare professionals are planned within the Transform AKC project.
The study will be subject to the audit and monitoring regimen of the UKKA. A governance framework will not be required for this scoping review.
We will use robust methodology to identify the existing literature describing the best practices in care of adults with advanced CKD. This review does not include participants or unpublished secondary data and therefore does not require ethical approval. As discussed above, the review results will be shared directly with the Transform AKC project team, and we then anticipate publishing the results in an academic journal and presenting findings at national conferences such as UK Kidney Week.
In summary, this review will use an MDT of clinicians with expertise in caring for patients in the AKC setting to identify best practices that can guide quality improvement interventions in the UKKA’s Transform AKC project. This scoping review may also identify gaps in the literature that will be priorities for future research. Only by clarifying the evidence base underpinning current AKC practices can we rationally look at what may work in driving improvement in AKC services across the country.
Not applicable.
The authors would like to acknowledge the support of the wider Advanced Kidney Care Kidney Quality Improvement Partnership team.
