Inter-CEPt: Intervening to eliminate the centre effect variation in home dialysis use

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?

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.

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.

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

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.

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).