Abstract Background Chronic kidney disease (CKD) is common, associated with substantial comorbidity and strong socioeconomic gradients. Early CKD care focuses on preventing disease progression and reducing cardiovascular risk. However, inequities in access to CKD care are most pronounced early in the disease course, a critical window for equitable population-level prevention within primary care. Understanding how these inequities arise within primary care, where early identification and management largely occur, is therefore essential. This study explored how people living with CKD in deprived areas of Scotland, a setting characterised by marked health inequalities, establish candidacy for early kidney care at a point when prevention should begin but is often lacking. Methods A qualitative study informed by critical realism combined semi-structured interviews with 38 adults with CKD (predominantly Stage 3 and primarily managed in primary care) and focus groups or interviews with 23 primary care professionals ( N = 61). Participants were drawn from the most deprived 40% of neighbourhoods across three Scottish health boards, ensuring variation in CKD stage, diagnosis timing, professional role, and urban-rural setting. Data were analysed using reflexive thematic analysis informed by the Candidacy Framework. Results Early kidney care for working-age adults living in deprived areas is often delayed, with CKD detected when personal resources, including time, finances, and support, are already stretched. Diagnosis is typically explained briefly, if at all, leading to uncertainty about its significance and next steps. Communication and care vary widely, with many patients relying on personal persistence to navigate fragmented healthcare systems. Care frequently depends on professional discretion, with uneven community and voluntary resources bridging gaps in care. These patterns reflect structural constraints rather than individual disengagement. Conclusion Early kidney care in communities experiencing deprivation represents a constrained preventive window within primary care. The “triple invisibility” of early CKD, at population, system, and symptom levels, undermines sustained engagement at the point when intervention is most effective. Strengthening equitable prevention requires service-level redesign and workforce models that embed kidney health within routine cardiometabolic care, address structural constraints in deprived areas, and integrate physical and psychosocial risk management. Trial registration Not applicable.

INTRODUCTION:Previous randomized trials and real-world observational studies of electronic alerts for acute kidney injury (AKI) have yielded conflicting results. The applicability of trial findings to routine clinical practice is also contested. Despite this, AKI e-alerts remain widely implemented. Here, we used Regression Discontinuity Design (RDD) to evaluate the real-world causal effect of the nationwide AKI e-alert initiative in Wales. METHODS:The study encompassed hospital and community-based systems serving 3.1 million adults (aged 18 years and older) residing in Wales, 2016-2020, following implementation of AKI e-alerts across all Welsh health boards, seven using passive alerts and one using interruptive alerts. We assessed outcomes across the e-alert threshold, including mortality, hospital admission/readmission, AKI severity and recovery, documentation of AKI, prescribing, and follow-up monitoring of proteinuria and blood pressure. RESULTS:Among 861,494 hospital and 354,505 community patient encounters, AKI alerts were triggered in 5.8% and 2.0% of cases respectively (mean age 64 years, 54% female). In both settings, AKI alerts led to no significant changes in mortality [complier average treatment effect +1.31% (95% Confidence Interval -3.07, 4.74); +2.07% (-3.44, 6.65)] or admissions/readmissions [+0.13% (-3.82, 4.21); +4.07% (-1.84, 8.27)]. AKI coding was infrequent across both settings. Alerts modestly increased hospital coding [+5.88% (2.22, 7.58)] but had minimal impact on primary care coding post discharge [+0.72% (-0.67, 1.30)] and led to only small improvements in proteinuria and blood pressure monitoring. Findings were consistent across passive and interruptive alert types, clinical settings and subgroups. CONCLUSIONS:We found no causal evidence that AKI e-alerts (specifically implemented at a 50% creatinine rise threshold) improved or worsened clinical outcomes in this nationwide real-world evaluation. Consistently poor outcomes, limited documentation and follow-up care, even in the presence of e-alerts, underscore the need for an improved clinical response to AKI.

BACKGROUND:The increasing prevalence of dementia is expanding the role of primary care in its management. However, inequities exist in primary care for people with dementia, particularly related to socioeconomic status. Individuals from socioeconomically disadvantaged areas are underrepresented in research on this topic. AIM:To explore primary care experiences of people with dementia and their carers from socioeconomically disadvantaged areas. DESIGN AND SETTING:Qualitative interviews with people with dementia and their carers recruited from deprived localities (Index of Multiple Deprivation quintile 1 or 2 postcodes). METHOD:We undertook 20 semi-structured interviews. Participants were purposively sampled by postcode via the Join Dementia Research database. Participants were aged >18 years, with any type of dementia or were a carer for someone with dementia. Data were analysed using reflexive thematic analysis. RESULTS:We identified four interrelated themes. These were: proactive continuity as a means of maintaining identity amid impending loss; the paradox of healthcare support falling away as it becomes needed more; challenges with accessing and navigating the primary healthcare system; and uncertainty around where dementia health care sits within primary care. Views about the impact of socioeconomic disadvantage varied. Some participants felt local resources, or individual social capital, affected the health care they received. CONCLUSION:Changes in primary care, including proactive contact, clearer communication of dementia-related care, and consistent relationships could improve patient experience. Clarifying primary care's role in dementia management is essential, especially with proposed shifts towards primary care-led post-diagnostic support. Further work is needed to establish if these experiences are described by people with dementia across all social strata or are specific to areas of socioeconomic disadvantage.

INTRODUCTION:Diagnostic subtype has been suggested as a determinant of inequity for people with dementia; its impact on primary care provision is underexplored. This study investigated the association between dementia subtype and likelihood of receiving guideline-consistent primary care. METHOD:Retrospective cohort study using Clinical Practice Research Datalink (Aurum) database, 1.1.2006-30.06.2024. We examined potential inequity with eight dementia subtypes: Alzheimer's disease (AD), Lewy body dementia (LBD), vascular, frontotemporal, unspecified, other and two mixed categories. Six outcomes were examined: care plan or medication review (both within 24 months of index) and four indicators of potentially inappropriate prescribing (PIP) (high anti-cholinergic burden drugs, z-drugs, benzodiazepines and anti-psychotics). Cox-regression models were used, adjusting for: age, sex, comorbidities, deprivation and ethnicity. RESULTS:A total of 571 663 people were included and 72.1% received a care plan; 79.4% received a medication review within 24 months. Compared to AD: people with mixed dementias were more likely to receive a care plan [hazard ratio (HR) 1.29, 95% confidence interval (CI) 1.26-1.32 for mixed including AD/LBD, HR 1.37, 1.32-1.43 for mixed non-AD/LBD]. All other subtypes were less likely to receive a care plan. Individuals with mixed AD/LBD (HR 1.28, 1.26-1.32), mixed non-AD/LBD (HR 1.35, 1.26-1.45), vascular (HR 1.05, CI 1.04-1.07), LBD (HR 1.02, 1.01-1.04) and unspecified (HR 1.02, 1.01-1.03) were more likely to receive medication reviews. Compared to AD, all other subtypes were more likely to experience PIP across all four indicators. CONCLUSION:We found greater likelihood of PIP in people with non-AD dementias, a novel finding. Further research is needed, especially with new AD drugs potentially widening disparities.

ObjectiveEvidence suggests that patient-level characteristics such as socio-economic status or ethnicity affect the likelihood of receiving guideline recommended anti-dementia medications. Existing studies often included all-cause dementia, not just the specific subtypes in which medication is indicated. Patterns of prescribing of Acetyl Cholinesterase Inhibitors (AChEIs) and memantine require further exploration, with little evidence about rates of co-prescribing in English primary care. We examined variations in anti-dementia medication prescribing with patient-level characteristics, and over time.Design and settingRetrospective cohort study, using the Clinical Practice Research Datalink Aurum. Data from 1,489 practices, in England between 2006-2024, were included and linked to patient level Index of Multiple Deprivation data (2019). Cox-regression modelling, clustered at practice level, assessed association between patient-level characteristics and receiving AChEIs, and/or memantine. Time-series analyses examined co-prescribing of memantine and AChEIs.Participants242,007 patients, aged >=18 years, with Alzheimer's or Lewy-Body Dementia, or mixed dementia including one of these subtypes, were included.ResultsAmong the 242,007 patients, 63.1% were prescribed an anti-dementia medication; co-prescribing of memantine and AChEIs peaked at 4.2%. Those in the most deprived quintile were less likely to be prescribed AChEIs (Hazard Ratio (HR) 0.82,0.78-0.86) compared to the most affluent quintile. People with Asian (HR 0.89,0.84-96), or Black (HR 0.79, 0.73-0.86) ethnicities were less likely to be prescribed memantine compared to white people. Those with learning disabilities were substantially less likely to be prescribed AChEIs (HR 0.46,0.42-0.50) or memantine (HR 0.58, 0.50-0.67) compared to those without.ConclusionOverall rates of prescribing of anti-dementia medications were lower than expected. Rates of co-prescription of AChEIs and memantine were low, despite guideline recommendations. We found inequity in anti-dementia medication prescribing, relating to multiple patient-level characteristics highlighting the need for more equitable access to evidence-based treatments.

Acute kidney injury (AKI) is a clinical syndrome characterised by a sudden deterioration of kidney function. It is common and usually occurs as a complication of severe illness or major surgery. Despite the high risk of complications and a decade of improvement initiatives in the UK, little is known about the quality of post-discharge AKI care. Our population-based cohort study investigated adherence to guideline-recommended post-AKI care in general practices in England. Using English hospital admission data (2017–2021), we created a cohort of discharged patients (≥ 18 years) with a hospital diagnostic code of AKI. Using linked Clinical Practice Research Datalink Aurum primary care data, we examined percentages of AKI episodes meeting the criteria of 14 guideline-recommended post-AKI care indicators, covering: AKI coding in primary care, post-discharge primary care contacts, kidney health and blood pressure monitoring, and guideline-indicated prescribing. Variations of indicator adherence according to patient characteristics were quantified using binomial mixed regression. 209,222 patients (48.0

BackgroundPeople affected by Acute Kidney Injury (AKI) experience poor short and long-term outcomes following discharge from hospital. Attempts to improve care have recognised the complexity of the healthcare system. We applied systems methods to explore everyday work and illuminate areas important for success, challenges faced and how people adapted to these challenges.MethodsTwenty-six patients who had recently been discharged from six hospitals after an admission complicated by AKI were interviewed. Focus groups were conducted with healthcare staff across six sites in England. Using the Functional Resonance Analysis Method (FRAM), the activities undertaken by patients and professionals across the primary-secondary care interface were modelled and interactions examined. The Systems Thinking for Everyday Work (STEW) principles were then applied to understand how people coped with system challenges to achieve successful outcomes.ResultsTwenty-two interacting activities were identified and modelled. These formed three interlinked subsystems that underpin effective management after an admission affected by AKI: (1) generating a post-AKI plan; (2) involving patients in their care; and (3) enacting the plan following discharge. Within these, seven themes captured the key challenges. Senior oversight of discharge planning was inconsistent, and staff preparing discharge documents felt under pressure and had to make trade-offs between competing priorities. Patients reported anxiety and vulnerability and yet were expected to be active participants in their care with little evidence of education and involvement. Finally, enacting the post-AKI discharge plan in the community was complicated by inadequate communication, imperfect systems with limited capacity and tensions between short-term stability and long-term condition management.ConclusionTo optimise follow-up care for people affected by AKI, development of improvement strategies should focus on co-design of interventions with patients and healthcare professionals to address the inherent trade-offs at discharge and strengthen coordination across care boundaries.

Acute kidney injury (AKI) is a common, harmful and costly clinical syndrome with high rates of unplanned readmissions and poor long-term health outcomes. Recent understandings, expounded in the concept of ‘Lifeworld’, place the healthcare needs of patients within the wider context of their lives. We aimed to explore patients' lived experience of care following an AKI and healthcare professionals perspectives of the management of AKI and relational work in that context.We interviewed 26 patients from six hospitals who had recently had an admission affected by AKI; 11 patients participated in further follow up interviews. We conducted 6 focus groups at separate sites across England with a total of 35 healthcare professionals from secondary and primary care. A reflexive thematic analysis was undertaken of the personal holistic stories of patients leading to interpretation of themes, confirmed by detailed analysis of the health professional focus groups.We interpreted three themes from the interview and focus group data: ‘Patient vulnerability: From hospital to the wider contexts of patients’ lives; ‘Understanding AKI in context: Challenges communicating kidney care’; ‘Feeling lost and adrift: Challenges navigating follow-up care after AKI’. Patients expressed feelings of vulnerability, needing reassurances about their ongoing kidney health. Patients had little awareness of AKI, or clarity of how kidney aspects of care were integrated into wider ongoing management.Practitioners, researchers, educators and policy makers might reflect upon ‘Lifeworld’ care approaches, particularly within relational work in aftercare, and consider the complex contexts of patient subjective experience in which AKI may occur.

Despite a decade of initiatives in the UK to raise awareness of acute kidney injury (AKI) and isolated reports of progress through improvement work in some regions, concerns remain that people who have had AKI do not receive adequate follow-up and care after transitioning from hospital back into the community. People discharged from hospital after AKI often have complex health needs and multiple long-term conditions, are at high risk of multiple poor outcomes and have high rates of unplanned readmissions. There is therefore a need to examine factors that are associated with variations in post-discharge AKI care. As part of the AsterAKI study, a mixed methods study aiming to develop interventions to improve post-discharge AKI care in primary care, we performed a cohort study to describe variations in the implementation of recommended post-discharge AKI care. Using admission data in England from Hospital Episode Statistics, we delineated a cohort of adult patients (≥18 years) with a hospital diagnostic code of AKI discharged between 1 January 2017 and 31 March 2021. Using linked primary care data from the Clinical Practice Research Datalink Aurum, we measured adherence to indicators of good care covering domains of (1) recording of AKI in primary care, (2) timeliness of post-discharge clinical reviews, (3) recommendations to monitoring of recovery at 90 days, and (4) guideline indicated prescribing. We evaluated care quality both overall, and within subgroups based on demographic, socioeconomic, and clinical characteristics. A total of 209,222 patients (48.0% females; mean age 74.1 years, SD 15.6) were included in the study cohort, representing 279,187 AKI hospital inpatient episodes. While some form of clinical contact (either in person or remotely) was made within 30 days of discharge for 72.5% of episodes, only 19.5% had a diagnosis of AKI hospitalisation recorded in the primary care notes. These percentages rose to 88.1% and 22.0% respectively at 90 days. Variations by demographic and socioeconomic factors were observed. At around 90 days post-discharge, measurement of serum creatinine for kidney recovery occurred in 34.2% of episodes, blood pressure was recorded in 34.6%, and urine albuminuria testing in only 3.8%. Of people with a guideline indication for a renin-angiotensin system inhibitor (RAASi) based on diabetes/hypertension and proteinuria levels, only 42.1% received a prescription. Across all subgroups of people with a hospital diagnostic code of AKI in this analysis, AKI was rarely documented in the patient's primary care records, and only a minority received the recommended post-AKI monitoring of blood and urine testing or blood pressure measurement, despite relatively high levels of contact with health care professionals. Rates of measuring albuminuria were particularly low, despite its strong association with subsequent kidney and cardiovascular events. Further, rates of prescribing of RAASi were low in patients who could benefit from these medications. Recommendations to improve this include provision of clear, case-specific guidance on post-discharge management to primary care professionals, and development of concerted implementation strategies between secondary and primary care.

BackgroundPatients with biochemical evidence of chronic kidney disease (CKD) without a diagnostic code (uncoded CKD) in primary care are at increased risk of death, acute kidney injury (AKI), and unplanned hospital care. Uncoded CKD is highly prevalent and there is no data to evaluate whether patients with uncoded CKD were at an increased risk of COVID-19 death. Aim: to assess whether patients with uncoded CKD stages 3-5 were at increased risk of death and COVID-19 deaths.MethodsDescriptive and inferential analyses to measure adjusted hazard of death, and COVID-19 death in patients with CKD stages 3-5 from 2.85 million primary care patients in Greater Manchester, England. Sensitivity analyses using propensity score matching and competing risk regression.ResultsCoded CKD stages 3 and 4 (versus uncoded) were associated with significantly lower adjusted hazards of death (HR 0.81, CIs 0.77-0.86, p=<0.0001; HR 0.45, CIs 0.34-0.60, p=<0.0001, respectively), and COVID-19 death (HR 0.74, CIs 0.55-0.99, p = 0.03; HR 0.55, CIs 0.30-0.99, p = 0.045, respectively). Descriptive analyses were conducted for patients with CKD stage 5 due to low numbers of patients with uncoded CKD stage 5, precluding survival analyses.ConclusionOur retrospective cohort study suggests that clinical coding is a digital intervention associated with a lower adjusted hazard of death and COVID-19 death in patients with CKD stages 3 and 4, and should be considered a key element in the organisation and delivery of care for people with CKD.

Background:Existing population research has evaluated inequities in health outcomes for people in deprived communities who have early kidney disease, but not the differences in their self-reported overall health and ability to manage daily life activities when they first present, or the additional burden for people of working age. Using their responses to the national Census in Scotland, we studied the self-reported overall health and impact on day-to-day life of people in deprived and affluent households who newly presented with evidence of kidney disease. Methods:Of 458 897 adult North Scotland residents, we included all 24 775 individuals who presented with new onset kidney disease (eGFR <60 ml/min/1.72 m2) in 2011-2014. We measured deprivation based on household (Census) and resident neighbourhood (index of multiple deprivation). We fitted proportional odds regression models that accounted for age, sex, comorbidities, and additional impairments (e.g. vision, hearing, learning difficulties). We further adjusted for self-reported mental health and living alone as potential mediators, and tested for interactions with working age (18-65 years), sex, and mental health. Results:Of 24 775 people newly presenting with kidney disease, already 11 115 (45%) reported limitations in their daily lives. People in the most deprived (vs least) neighbourhoods and households experienced 2-fold greater odds of worse self-reported health (adjusted odds ratio, OR 2.05, 1.81-2.32 neighbourhood; OR 1.93, 1.64-2.26 household); and greater limitation in day-to-day activities (OR 1.70, 1.49-1.95 neighbourhood; OR 1.65, 1.39-1.96 household). This pattern of inequity was even more pronounced (3-fold) among those of working age (interaction P < .0001). Conclusion:The association of deprivation with health and daily life represents an additional dimension of health inequity that is substantial, and evident from the earliest stages for people with kidney disease.

BACKGROUND:Communication between patients and staff is a crucial component of safe and effective healthcare. As people age, they have more consultations and these become more complex. As such, older people may be more likely to experience gaps and breakdowns in communication. OBJECTIVE:To develop a better understanding of older people's communication in interactions with primary care staff and the barriers to and enablers of this. SEARCH STRATEGY:Four databases were searched. Search terms covered the sample (older people), domain (verbal communication in healthcare interactions), context (primary care) and research type (qualitative research). DATA EXTRACTION AND SYNTHESIS:A meta-ethnographic approach was followed by one researcher, with input from the wider team. Twelve studies were included. Details of the designs, participants, methods and results were extracted. Data were synthesised through reciprocal translation, and a line of argument was developed. MAIN RESULTS:Barriers to communication were found in relation to raising and addressing concerns. Barriers arose from patient perceptions of their role, the nature of their relationship with staff, patient and staff perceptions of responsibility and reluctance to broach a topic, individual factors such as memory, how staff respond when concerns are raised and the degree of patient involvement in consultations. Potential enablers of communication were preparation and support from family or peers. CONCLUSIONS:Synthesising the existing qualitative literature on older people's communication in healthcare interactions enabled the identification of barriers and enablers that can be used to inform the development of an intervention to improve communication with primary care staff. PATIENT OR PUBLIC CONTRIBUTION:By identifying healthcare communication as the most important topic for the patient safety of older people with multiple long-term conditions in primary care and setting the scope of the review, patients and the public were involved in the design of the study. Four public contributors (older people with multiple long-term conditions and carers of older people with multiple long-term conditions) attended regular meetings, provided their reflections on the study findings and supported the interpretation of the data.

Chronic kidney disease (CKD) is a growing global health concern requiring effective self-management to mitigate progression and improve quality of life. While self-management is increasingly recognised as a socially embedded practice, the specific contributions of social network members to this process in CKD are not well understood. To synthesise and interpret existing literature on how social networks support individuals living with early-stage CKD and identify gaps in understanding. We conducted a narrative review. Fourteen studies involving 560 participants—including individuals living with CKD, their social network members, healthcare professionals, peer mentors, and religious leaders—were analysed to explore the role of social networks in CKD self-management. Four key themes emerged: (1) The burden of kidney disease uncertainty (2), Everyday challenges of managing CKD (3), The loneliest disease, and (4) The role of peer support. Participants frequently reported emotional distress linked to diagnostic uncertainty and inconsistent information, especially from non-specialist providers. CKD management posed significant practical and psychological burdens, particularly for caregivers, who often felt unsupported and invisible within healthcare systems. Peer support—both informal and formal—played a crucial role in reducing isolation and providing context-specific guidance, especially when tailored to individual preferences and illness trajectories. This is the first review to explore the role of social networks in supporting the self-management of people living with CKD. The studies highlighted that early-stage CKD is shaped by diagnostic uncertainty, limited formal support, and social invisibility. People with CKD rely on diverse social networks for self-management, yet unclear care pathways and inconsistent communication hinder this support. Integrated models that combine early specialist input, peer support, and trained generalists are needed. Recognising and supporting these networks is essential to reduce isolation, improve understanding, and enable meaningful engagement with self-management across the CKD trajectory.

Poor communication is a key causal factor of medication safety incidents. Collaboration between community pharmacy (CP) and general practice (GP) staff is essential but hindered by multiple barriers. This study applied an Experience-Based Co-Design (EBCD) approach, incorporating Systems Thinking for Everyday Work (STEW), to develop interventions for improving collaboration and communication on medication safety across the GP-CP interface. A sequential study design was undertaken, including: 1) an experience gathering phase to understand the communication of medication safety issues across the GP-CP interface, involving online focus groups and interviews with 27 GP and CP staff; and 2) two online EBCD workshops with 21 participants, including patients and primary care staff, to generate and prioritise interventions for improving medication safety communication and collaboration. Focus groups, interviews and workshops were audio-recorded, transcribed, and thematically analysed. Three key touchpoints for communication and collaboration on medication safety issues were identified: medication errors, medication changes, and potential patient safety concerns. An absence of shared communication approaches and the prioritisation of medication safety issues, one way communication tools, lack of understanding of professional roles and of incident reporting processes were barriers to communication and collaboration. Facilitators included GP pharmacist-community pharmacist relationships, face-to-face interactions and staff continuity. Five key interventions were suggested: development/modification of an electronic two-way communication tool between GP and CP; centralisation and sharing of patient records; interprofessional education; co-location of general practices and community pharmacies; and a toolkit for improving medication safety across the GP-CP interface. Participants agreed that a toolkit to address key communication and collaboration issues arising at multiple touchpoints should be prioritised for development and discussions led to refinement of ideas and production of a toolkit blueprint. Further research is required to refine toolkit resources, establish an implementation pathway, and evaluate its effectiveness to support adoption and improvements in medication safety.

INTRODUCTION:International guidelines make recommendations for the delivery of safe, high-quality primary care for people with dementia including prescribing, personalised care planning and regular holistic reviews. It is unclear how the quality and safety of this healthcare varies with socio-economic factors. OBJECTIVE:This scoping review aimed to understand the depth and breadth of existing evidence exploring socio-economic variation in the quality and safety of primary care for people with dementia. METHODS:Prescribing and care planning indicators of high-quality, safe primary care were defined from guidance. Composite and proxy markers of socio-economic status (SES) were defined. EMBASE, MEDLINE, PsychInfo, The Cochrane Database of Systematic Reviews, worldcat.org and clinicaltrial.gov databases were searched. Studies in English, on human participants from 2006 onwards were eligible. Narrative synthesis was conducted. Studies explored how one or more selected indicators (anti-dementia medication and anti-psychotic prescribing, potentially inappropriate prescribing (PIP), medication review, dementia review or care planning) varied with a recognised marker of SES in people with dementia. RESULTS:Searches identified 1980 studies after removing duplicates. 385 full texts were reviewed, with 53 eligible for inclusion (51 quantitative, 2 reviews). Most identified studies explored prescribing processes (50 quantitative, 2 reviews), with 2 exploring annual review. There was evidence of substantial disparity in quality and safety indicators in studies exploring prescribing; 20/29 (69%) of studies exploring anti-dementia medication prescribing found those with markers of lower SES were significantly less likely to receive these. 16/28 studies exploring PIP/Anti-psychotics found significant disparities in safe prescribing for those with markers of lower SES. Neither study exploring annual reviews found any significant differences across SES. CONCLUSION:We found evidence of disparity in the quality and safety of post-diagnostic primary care for people with dementia based on SES, particularly for a range of prescribing indicators. Further work exploring inequalities in care planning and reviews for people with dementia is needed to understand existing inequalities in the quality and safety of primary care for people with dementia.