Title: Inter-CEPt: Intervening to eliminate the centre effect variation in home dialysis use
Funder: Department of Health and Social Care

Abstract: 30,000 people with kidney failure in the UK have their treatment, called dialysis, either at home or by travelling to their local dialysis unit as an out-patient, where it is provided by staff. National guidelines encourage the use of home dialysis treatment because there are many advantages. Patients find it more convenient and are more satisfied with their treatment. This greater degree of independence and understanding of their treatment may be why they are more likely to do better on dialysis. _x000D_ _x000D_ The problem is that some kidney treatment centres provide home treatment to more patients than other centres, varying between 2 and 28% of the total. A recent study from the Renal Registry, a national databank with all the information about kidney patients also found that certain groups in our society were less likely to have home therapy. Those groups include people from black and ethnic minorities and poorer or disadvantaged backgrounds. This is worrying because equality and fairness is important in the NHS. In this study, we aim to understand the complex reasons why home therapies are not used more equally and fairly by kidney centres across the country. We will also design and test a number of possible solutions to improve the uptake of home therapies._x000D_ _x000D_ This study has five parts:_x000D_ (1) Because existing research suggests that the way a centre is organised and how teams work together is important, we will undertake a detailed investigation in four centres with varying success in using home therapies to gain deep insights into the reasons of these differences in uptake. It will involve observing kidney patients, their nurses and doctors, NHS managers, especially how they work together. _x000D_ (2) We will use these insights to create a survey of all centres across the country. The results will be analysed in a way that incorporates all factors that can explain variation between centre in the use of home therapies, such as the centres’ kidney transplant rates, geography and distances for patients to travel. _x000D_ (3) Because home therapies have been shown to be cheaper, there are potentially very significant savings for the NHS, maybe up to £45 million over 3 years. We will use the information from our research to determine the savings that could be realised. _x000D_ (4) We will combine all this new knowledge to work out what the most important factors are that are likely to improve home therapy use that is equal and fair. _x000D_ (5) We will use this research to develop an approach that can be applied by centres that is acceptable to patients and staff as well as being practical and feasible. Examples of what this might include would be illustrations of best practice, how centres use the payments they receive to deliver dialysis care, awareness of prejudice, training in how to avoid this and use of services that assist patients to use home therapies._x000D_ _x000D_ This research will benefit patients and the NHS by improving uptake of home therapies, helping people with kidney disease improve their quality of life and reducing costs. Patients will be involved throughout the research in design, interpretation, advising on intervention development, study oversight and reporting, including understandable messages to publicise our findings. We will share the findings with commissioners and service providers through the dialysis Clinical Reference Group and Think Kidneys Home Dialysis campaign as well as more widely to renal and health service conferences and publications.

Lay abstract: RESEARCH QUESTION What are the factors driving centre variation in uptake of home dialysis, and how do these inform the design of an intervention bundle to overcome this?_x000D_ _x000D_ BACKGROUND Use of home dialysis by centres varies considerably and is decreasing despite attempts to encourage greater use (e.g. NICE guidance). Renal Registry analysis shows underuse of home therapies in ethnic minorities and more socially deprived patients. Health economic analysis suggests more home therapy use would be a potential saving to the NHS but there is significant uncertainty especially when more marginal patients are treated._x000D_ AIMS AND OBJECTIVES To gain robust understanding of the factors driving centre variation in the uptake of home dialysis requires an in-depth understanding of the cultural and organisational factors contributing to centre variation and how these relate to quantifiable performance at the local level accounting for competing treatment options. This knowledge will be used to identify which factors would inform a practical and effective intervention bundle embedded within a contemporary economic model of dialysis costs with the objective of ensuring our intervention is realistic and cost effective._x000D_ _x000D_ METHODS Underpinned by the NASSS framework our research will use an exploratory sequential mixed methods approach. Qualitative insights derived from multi-sited focused team ethnography, conducted at 4 case-study sites (WP1) will directly inform the intervention as well as the development of a quantitative survey of 50 dialysis centres. Survey results will be linked to patient level use of treatment modalities and outcomes as recorded by the Renal Registry (WP2). Economic evaluation (WP3) will also use the Registry data to undertake contemporary cost-effectiveness modelling as well as determining how this might be affected by modification of factors identified in WPs 1&2, so ensuring that the detailed synthesis of factors that explain centre variation in home therapy uptake (WP4) identifies those most likely to yield the greatest cost benefit. This synthesis will lead to selection of candidate components from which we will develop, using the COM-B framework for behaviour change interventions, the optimal intervention bundle (WP5) through workshops with patients and healthcare professionals to ensure acceptability, feasibility and cost effectiveness. PPIE is embedded throughout the project_x000D_ _x000D_ TIMELINES WP1 informs survey development by 10m and finalises outputs by 18m. WP2 extracts Registry data by 3m, modality use and outcome modelling by 12m, completes survey by 16m finalising linked survey/registry analysis by 22m. WP3 develops contemporary economic model by 15m. Data synthesis (WP4) completes by 24m informs development of intervention bundle by 30m, finalization of outputs 32m._x000D_ _x000D_ ANTICIPATED IMPACT AND DISSEMINATION The intervention bundle will comprise components for all stake-holder groups: commissioners, provider units, recipients of dialysis their care-givers and families. Examples include guidance for commissioners, financial incentives, recognition of bias, greater support for certain patient groups, innovative approaches to overcoming barriers. With our advisory group we will ensure that our research reaches all these groups using a variety of methods: events, short guides, infographics, case studies, guidelines, (e.g. NICE, Renal Association), patient conferences, GiRFT initiative, Clinical Reference Group (Dialysis).

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: RENAL AND UROGENITAL