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ObjectiveIdentifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care.DesignA rapid realist review.Data sourcesCochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022.Eligibility criteria for selecting studiesWe considered all types of empirical studies describing interventions targeting frailty in primary care.AnalysisWe followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation.ResultsOur primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need.ConclusionThere remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence.PROSPERO registration numberThe published protocol for the review is registered with PROSPERO (CRD42019161193).

BACKGROUND: Reducing the harms associated with acute kidney injury (AKI) requires addressing a wide range of patient safety issues, including polypharmacy and transitions of care, particularly for vulnerable patient groups. Computerised audit and feedback can transform the way healthcare organisations measure, analyse and learn from quality and safety data across different care settings, potentially improving patient safety.OBJECTIVE: To implement and evaluate an audit and feedback dashboard targeting AKI to improve patient safety, focusing on factors affecting a range of user characteristics in primary care.METHODS: We performed a mixed methods study in three stages. Semi-structured interviews were initially performed with both primary (n = 10) and secondary care (n = 5) staff to gather user requirements for six quality indicators extracted from national guidance on post-discharge AKI care. Modified indicators were implemented in the Performance Improvement plaN GeneratoR (PINGR) audit and feedback dashboard for six months, across 45 general practices in Salford. Primary care professionals were then interviewed again (n = 7) and completed usability questionnaires. This was triangulated with an interrupted time series analysis on indicator performance, alongside software usage statistics.RESULTS: Improvements were observed for the indicators for medication review (+9.01 %; 95 % Confidence Interval (CI), +6.95 % to +11.06 %) and blood pressure measurement (+5.20 %; 95 % CI + 3.61 % to +6.78 %). Variable performance and engagement were observed for other indicators including AKI coding (+0.39 %; 95 % CI -1.88 % to +2.65 %), serum creatinine (-3.40 %; 95 % CI -7.66 % to +0.85 %), proteinuria (-1.08 %; 95 % CI -1.47 % to +0.32 %) and providing patient information (+0.16 %; 95 % CI -0.41 % to +0.73 %). A key facilitator to engagement was the development of 'champions of change', achieved through a raised awareness of high-risk patients, guidelines, inconsistencies in coding practice and evidence for quality and safety performance. Barriers related to the specificity and perceived achievability of indicators, and limitations in resources.CONCLUSION: In a six-month, quasi-experimental evaluation of an electronic audit and feedback dashboard targeting AKI, we found improvements for two out of six quality indicators. While information technology can facilitate improvements in patient safety, further allocation of protected staff time and investment into shared learning are needed to realise those improvements in practice.

Objectives To identify the rates of potentially inappropriate antibiotic choice when prescribing for common infections in UK general practices. To examine the predictors of such prescribing and the clustering effects at the practice level. Methods The rates of potentially inappropriate antibiotic choice were estimated using 1 151 105 consultations for sinusitis, otitis media and externa, upper respiratory tract infection (URTI) and lower respiratory tract infection (LRTI) and urinary tract infection (UTI), using the Clinical Practice Research Datalink (CPRD). Multilevel logistic regression was used to identify the predictors of inappropriate prescribing and to quantify the clustering effect at practice level. Results The rates of potentially inappropriate prescriptions were highest for otitis externa (67.3%) and URTI (38.7%) and relatively low for otitis media (3.4%), sinusitis (2.2%), LRTI (1.5%) and UTI in adults (2.3%) and children (0.7%). Amoxicillin was the most commonly prescribed antibiotic for all respiratory tract infections, except URTI. Amoxicillin accounted for 62.3% of prescriptions for otitis externa and 34.5% of prescriptions for URTI, despite not being recommended for these conditions. A small proportion of the variation in the probability of an inappropriate choice was attributed to the clustering effect at practice level (8% for otitis externa and 23% for sinusitis). Patients with comorbidities were more likely to receive a potentially inappropriate antibiotic for URTI, LRTI and UTI in adults. Patients who received any antibiotic in the 12 months before consultation were more likely to receive a potentially inappropriate antibiotic for all conditions except otitis externa. Conclusions Antibiotic prescribing did not always align with prescribing guidelines, especially for URTIs and otitis externa. Future interventions might target optimizing amoxicillin use in primary care.

Objectives: Tackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care. Design: An appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method. Setting: Clinical scenarios were developed to test the timeliness in (1) communication of AKI warning stage test results from clinical pathology services to primary care, and (2) primary care clinician response to an AKI warning stage test result. Participants: A 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and 'overdiagnosis'. Results: There was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia. Conclusions: The study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs.

Background Chronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care. Methods A rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation. Results Our primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs. Conclusions Our rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0413-7) contains supplementary material, which is available to authorized users.

Osteochondroma of the bone can cause a range of complications involving tendons, joints and neurovascular structures. Distal fibular osteochondroma and non-traumatic peroneal tendon subluxation are both rare. In this case report, we describe an unusual case of distal retrofibular osteochondroma in a 36-year old male causing peroneal tendon subluxation. He presented with pain and instability around his ankle, but with no history of trauma. He successfully underwent osteochondroma excision, peroneal groove deepening and a Brostrom-Gould type reconstruction for the lateral ankle ligament insufficiency. Complete resolution of the symptoms of instability and subluxation was noted upon 6-month follow up.