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Work packages
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Baseline mapping of current collaboration
A quantitative, register-based description of referral patterns, communication practices, and role distribution between nephrology and general practice in CKD care — with particular focus on the specialist perspective on referral quality and triage burden.
Objectives
- Describe current referral patterns from general practice to nephrology in Nordjylland Region
- Characterise nephrologists' experience of current collaboration, referral quality, and workload
- Quantify the triage burden on nephrology departments
- Identify variation across practices, demographics, and CKD stages
Referral audit — six dimensions
| Dimension | Operational definition | Source |
|---|---|---|
| Quality | Structured assessment against pre-defined criteria (relevant clinical question, adequate clinical reasoning, appropriate urgency level) | Audit rubric · 2 raters, Cohen's κ |
| Relevance | Is the referral clinically indicated given current KDIGO 2024 guidance and regional referral criteria? | Audit rubric |
| Completeness | Presence of minimum data: eGFR trajectory, albuminuria, current medications, comorbidities, reason for referral | Checklist-based audit |
| Volume | Number of referrals per 1,000 registered patients per practice per year | Outpatient contact register |
| Rejection / redirection | Frequency of rejection, redirection to other specialty, or request for additional information | Local triage log |
| Triage time | Minutes of nephrologist time per referral (triage, information request, acceptance/rejection) | Prospective time-use log (optional) |
Data sources
Outcomes
• Referral completeness (% with minimum data set)
• Referral appropriateness (% accepted without need for further information)
• Variation across practices and patient subgroups
• Nephrology time-use per referral
Exploring needs & experiences across stakeholders
Qualitative research with GPs, nephrologists, and patients to explore experiences of current collaboration, perceived barriers and facilitators, and preferences for a strengthened support model.
Sample & purposive sampling
| Participant group | Target n | Sampling variation |
|---|---|---|
| General practitioners | 15–20 | Geography · practice size · years in practice · special interest in CKD |
| Nephrologists | 5–10 | Seniority · subspecialty (general neph, transplant, dialysis) |
| Patients with CKD 3–5 | 10–15 | CKD stage · comorbidity · age · experience of referral |
| Optional GP survey | 60–100 | Regional electronic survey if qualitative findings warrant quantification |
Methods
- Semi-structured interviews (45–60 min) using topic guides developed from WP1 findings and literature
- Optional focus groups if triangulation needed (e.g. mixed GP/nephrologist group to explore collaborative preferences)
- Reflexive thematic analysis (Braun & Clarke, 2021), data-driven and theoretically informed
- Dual coding of a subsample by supervisor; coding framework iteratively refined
- COREQ checklist for reporting of qualitative findings
- Reflexive memos throughout to attend to researcher positionality
Topic areas explored
Co-developing a collaborative support model
Rather than locking the intervention to one format from the outset, WP3 develops a flexible model adapted to local needs. Co-design is participatory, iterative, and anchored in findings from WP1 and WP2.
Possible model elements
The final intervention will be decided through co-design. It may include one or more of the following:
Co-design process
| Workshop | Focus | Participants |
|---|---|---|
| Workshop 1 | Present WP1/WP2 findings · prioritise needs · identify candidate model elements | 8–12: GPs, nephrologists, patient representatives, research team |
| Workshop 2 | Develop detailed workflows · draft eligibility criteria · identify implementation barriers | 8–12: same core group ± additional stakeholders |
| Workshop 3 (optional) | Refine model after pilot feedback · finalise implementation procedures | Core group + pilot practice representatives |
Reporting frameworks
- TIDieR (Template for Intervention Description and Replication) — detailed intervention description
- GRIPP2 — reporting of patient and public involvement
- Theory of change — explicit logic model linking inputs, activities, outputs, and expected outcomes
Piloting the model — feasibility & acceptability
A mixed-methods pilot evaluation in a defined setting (Nordjylland, possibly Vendsyssel). The primary aim is not effectiveness but feasibility: can this model be delivered in routine practice, and is it acceptable to those who use it?
Setting & sample
| Participant group | Target n | Recruitment |
|---|---|---|
| GP practices | 4–8 | Expression-of-interest · purposive selection for variation |
| Nephrology departments | 1–2 | NAU + possible secondary site |
| Patients (CKD 3–5, focus 3b–4) | 20–40 | Via participating GPs with clinically relevant need for shared care |
| Participating GPs | 8–12 | Within the 4–8 pilot practices |
| Participating nephrologists | 4–8 | Within the 1–2 departments |
Feasibility framework
Evaluation is anchored in Proctor et al.'s (2011) implementation outcomes framework, adapted for a feasibility study:
Data collection methods
- Activity logs & case-report forms — one per TC / consultation / sparring event
- Brief post-event surveys — immediate acceptability ratings from all three parties
- Follow-up interviews — with participating GPs, nephrologists, and a subset of patients at pilot end
- Pre/post referral audit — comparing referral volume and quality before and after the pilot in participating practices
- PROM/PREM measures (patient-reported outcome and experience measures) — to capture patient perspective (research extension, not protocol mandate)
- Observational field notes — selected TCs observed ethnographically by researcher
Success criteria
The questions driving KID-LINK
Five research questions and three hypotheses underpin the PhD project. Each question is addressed by one or more work packages.
Research questions
Addressed by: WP1 (quantitative baseline) + WP2 (qualitative exploration)
Approach: Register-based descriptive mapping combined with qualitative description of perceived role distribution from nephrologist and GP interviews.
Addressed by: WP2
Approach: Reflexive thematic analysis of semi-structured interviews. CFIR 2.0 (Consolidated Framework for Implementation Research) used as an analytic lens to structure findings across inner/outer setting, individual, and process domains.
Addressed by: WP3
Approach: Participatory co-design workshops. Explicit use of TIDieR for intervention description, theory of change for logic modelling, and GRIPP2 for PPI reporting.
Addressed by: WP4
Approach: Post-pilot semi-structured interviews, post-event surveys, and observational field notes from selected TCs. CFIR framing of organisational conditions.
Addressed by: WP4 (mixed methods)
Approach: Proctor et al. (2011) implementation outcomes framework — acceptability, appropriateness, feasibility, adoption, fidelity, cost. Pre/post comparison of referral quality in participating practices.
Hypotheses
What we measure, and why
A structured overview of primary and secondary outcomes for each work package. Primary outcomes drive the main analyses and publications; secondary outcomes provide triangulation and depth.
Primary outcomes
- Time from confirmed CKD to first nephrology contact
- Referral completeness (% with minimum data set)
- Referral appropriateness (% accepted without further information request)
Secondary outcomes
- Selected hospitalisations (cardiovascular, infection-related) if feasible
- Practice-level variation in referral volume
- Nephrology time-use per referral
Qualitative outcomes (themes)
- Experiences of current collaboration across sectors
- Role understanding and perceived boundaries
- Barriers and facilitators (mapped to CFIR 2.0 domains)
- Educational needs and preferences for sparring formats
- Preferences for support models (TCs, outreach, eConsult, etc.)
- Patient preferences regarding care pathways
Outputs
- A co-developed collaborative support model
- Intervention components (TIDieR-compliant)
- Implementation procedures
- Supporting tools and documentation templates
- Theory-of-change diagram linking inputs → activities → outputs → outcomes
Primary outcomes
- Feasibility (Can the model be delivered as designed?)
- Acceptability (Do participants find it agreeable?)
- Participation rates (% eligible patients/practices who enrol)
- Deliverability within routine practice workflows
Secondary outcomes
- Perceived improvement in communication
- Perceived clarity of roles
- GP and nephrologist satisfaction
- Perceived patient benefit (PROM/PREM)
- Exploratory changes in referral quality and relevance (pre/post)
The data landscape
A structured overview of variables measured, their operational definitions, and the data sources from which they are drawn. Each variable is linked to one or more work packages.
Core patient variables
| Variable | Operational definition | Source |
|---|---|---|
| Age, sex | At baseline (first observed CKD record) | CPR register |
| eGFR | CKD-EPI 2021 equation (race-free), in mL/min/1.73 m² | Labka |
| Albuminuria / uACR | Albumin-creatinine ratio in mg/mmol; KDIGO category A1/A2/A3 | Labka |
| CKD stage | KDIGO 2024 G1–G5 based on eGFR, with albuminuria category | Derived |
| Comorbidity | Diabetes, hypertension, cardiovascular disease, COPD, malignancy — ICD-10 codes (via LPR3) | LPR3 |
| Medication use | Relevant CKD-related prescriptions (optional sub-analysis) | Prescription register |
Referral & communication variables
| Variable | Operational definition | Source |
|---|---|---|
| Referral initiation | Binary: was a referral sent from general practice to nephrology? | Outpatient register · referral log |
| Time to first contact | Days from confirmed CKD (per registry algorithm) to first nephrology contact | Derived |
| Referral completeness | Structured audit against minimum-data checklist | Audit |
| Referral appropriateness | Audit per KDIGO 2024 referral criteria | Audit |
| Number & type of contacts | Outpatient, virtual, inpatient, telephone | Outpatient register |
| Requests for additional information | Binary per referral | Triage log |
| Documented shared plans | Presence of cross-sector shared care plan | Clinical correspondence |
Pilot implementation variables
| Variable | Operational definition | Source |
|---|---|---|
| Completed collaborative contacts | Count of delivered TCs, outreach visits, eConsults per practice | Activity log |
| Participation rate | % eligible patients who enrol; % GPs who deliver ≥1 TC | CRF |
| Time use | Minutes per collaborative event (by role) | CRF · activity log |
| Workflow feasibility | Self-rated 1–5 scale + free-text barriers | Post-event survey |
| Acceptability | Self-rated 1–5 scale across three parties | Post-event survey |
| Perceived usefulness | Self-rated 1–5 scale + free text | Post-event survey |
| Perceived impact on communication | Post-pilot interview themes | Interview |
The project year by year
Detailed month-by-month plan across the three PhD years (2026–2029). Milestones are indicative; actual dates depend on approvals and recruitment.
Months 1–6 · Setup
- Obtain approvals: Videnskabsetisk Komité (VEK), institutional DPO, Datatilsynet register-data permission
- Finalise the data management plan following FAIR principles
- Register the study protocol on a public registry (e.g. OSF, ClinicalTrials.gov if applicable)
- Establish supervisory and stakeholder structures (steering committee, advisory patient panel)
- Prepare quantitative data extraction procedures (WP1) and qualitative topic guides (WP2)
- Patient and public involvement (PPI) setup — identify patient representatives per GRIPP2
Months 7–12 · WP1 + WP2 launch
- Conduct baseline quantitative analyses (WP1) using Sundhedsdatastyrelsen registers and NAU local data
- Develop and pilot-test interview guides (WP2)
- Begin qualitative recruitment and interviews (GPs first, then nephrologists, then patients)
- Initiate descriptive mapping of current collaboration patterns
Months 13–18 · WP2 completion + WP3 launch
- Complete WP2 data collection, transcription, and thematic analysis
- Synthesise WP1 + WP2 findings as input to WP3
- Conduct co-design workshops (WP3) — workshop 1 and 2
- Draft the collaborative support model per TIDieR
- Submit first manuscript (WP1)
Months 19–30 · WP4 pilot
- Recruit 4–8 pilot practices and nephrology department(s)
- Deliver the pilot model for approximately 12 months in routine practice
- Collect activity logs, post-event surveys, and field notes ongoing
- Conduct interim feedback and iterative refinement (potential Workshop 3)
- Submit second manuscript (WP2)
Months 31–36 · Integration & thesis
- Complete final WP4 analyses (pre/post audit, interviews, surveys)
- Integrate findings across all four WPs
- Finalise manuscripts: WP3 co-design paper, WP4 feasibility paper
- Write the PhD thesis (synopsis + published papers)
- Conduct dissemination: stakeholder workshop, conference presentations, practice feedback
Ethics, data protection, and participant rights
KID-LINK is designed to comply with the Danish Code of Conduct for Research Integrity, GDPR, and the Danish Data Protection Act. This page summarises the ethical and regulatory framework.
Approvals required
Informed consent
- Written and verbal information provided to all participants in interviews, workshops, surveys, and pilot activities
- Separate consent items for: interview participation · audio recording · pseudonymised quotation in publications · follow-up contact
- Voluntary participation with right to withdraw at any time without consequences for clinical care or professional relationships
- Translated materials available where needed; interpreter support for non-Danish-speaking patients where feasible
- Accessible format for patients with literacy or cognitive considerations
Data protection measures
- Register-based data processed within secure institutional environment (forskermaskine / researcher VM) — never downloaded to personal devices
- Interview data pseudonymised immediately upon transcription; audio files stored separately from transcripts
- Key linking pseudonym to identity stored in a separate, access-controlled location
- Pilot data pseudonymised at source via the platform's KL-XX-000 ID system
- All research outputs quote pseudonyms only; any identifying detail redacted from quotations
- Retention period and destruction schedule specified in the DMP
Making findings matter — publication & practice
Dissemination targets both academic and clinical audiences, with explicit feedback to participating practices and regional stakeholders.
Peer-reviewed publications
Other dissemination
- Conference presentations — Danish Society of Nephrology, DSAM (Danish College of General Practitioners), international (ERA-EDTA, NAPCRG)
- Stakeholder workshop — final event involving participating practices, region representatives, patient advocates
- Practice feedback — tailored reports to each participating practice and nephrology department
- Lay summaries — accessible findings for patient participants and the public
- Policy brief — summary for regional health authorities and the Danish health ministry
- Open science — code, anonymised data where possible, and reporting templates on OSF
The KID-LINK protocol
A structured view of the full PhD protocol. For the original PDF, contact the research team.
The evidence base
Vancouver-style references underpinning the protocol. All 22 references are listed below.
Live transcription
Real-time speech-to-text with speaker tagging, timestamps, and theme markers. Uses the browser's Web Speech API — no audio leaves your device.
CKD calculator & staging
Enter eGFR and uACR to classify the patient by KDIGO 2024 stage and albuminuria category. Eligibility assessment is a clinical judgement, not an automated output.
uACR is an albuminuria parameter (KDIGO category A1/A2/A3), not a comorbidity.
Comorbidities (per protocol)
Tripartite consultation checklist
Interactive 10–30–10 checklist covering all three phases of a TC. Progress is saved locally in your browser.
CKD medication reference
Educational overview of classes of medication relevant to CKD management, aligned with the KDIGO 2024 CKD clinical practice guideline. This is a reference, not a prescribing tool.
KDIGO 2024 recommends SGLT2i for adults with CKD (both diabetic and non-diabetic kidney disease) who have eGFR ≥20 mL/min/1.73 m², with initiation at the same threshold. Continue until dialysis or transplantation unless otherwise indicated.
Key evidence
- DAPA-CKD, EMPA-KIDNEY trials — significant reductions in CKD progression and cardiovascular events
- Benefit extends across diabetic and non-diabetic CKD populations
Practical notes
- Expect a small, transient eGFR dip at initiation (usually <5 mL/min)
- Monitor for euglycaemic DKA (rare), genital mycotic infections
- Dose reduction of diuretics may be needed at initiation
ACE inhibitors or angiotensin receptor blockers are recommended for adults with CKD and albuminuria (particularly A2/A3), irrespective of diabetes status. Titrate to maximum tolerated dose.
Key considerations
- Check potassium and eGFR 1–2 weeks after initiation or dose change
- A 20–30% rise in creatinine at initiation may be acceptable; larger rises warrant investigation
- Not combined with direct renin inhibitors; dual RAAS blockade generally avoided
KDIGO 2024 suggests adding a non-steroidal mineralocorticoid receptor antagonist (finerenone) for adults with type 2 diabetes, eGFR ≥25 mL/min/1.73 m², and uACR ≥3 mg/mmol who are already on a maximally tolerated RAAS inhibitor. Monitor potassium.
Potassium binders (patiromer, sodium zirconium cyclosilicate) may enable continuation of evidence-based RAAS/MRA therapy in patients with mild-moderate hyperkalaemia. Dietary advice, diuretic adjustment, and review of contributing medications are first-line steps.
Statin therapy is recommended for adults ≥50 years with CKD not requiring dialysis. In younger adults, statins are recommended if additional CV risk factors are present. Dose adjustment per eGFR — consult local guidance.
Management of CKD-MBD becomes increasingly important from CKD stage 3b onwards. Interventions include phosphate binders, vitamin D analogues, and calcimimetics (dialysis patients). Refer to nephrology for advanced CKD-MBD management.
Structured field notes
Timestamped observational notes organised by observational focus. All notes are stored locally in your browser.
Reflexive memo
Participant questionnaire
Structured questionnaires for patients, GPs, and nephrologists. Instruments draw on validated scales where available; custom items developed for study-specific constructs.
Semi-structured interview guides
Topic guides for interviews with GPs, nephrologists, and patients. Each guide contains opening, main topics with probes, and closing prompts. Guides are iteratively refined as analysis progresses.
Plan your sessions
Calendar for interviews, co-design workshops, and pilot TC sessions. All entries are stored locally in your browser — no calendar integration, no cloud sync.
Spillover log
Record instances where learning from a tripartite consultation was later applied to other CKD patients who did not directly participate. This captures an important secondary outcome of cross-sectoral collaboration.
Consent form generator
Generate a pseudonymised consent form in Danish or English. Forms are templates — always confirm with institutional standards before use.
Print & PDF
Print-ready versions of key documents. Use your browser's print function (⌘/Ctrl + P) to generate a PDF.
Anonymisation hub
Generate pseudonyms, scan text for potential identifiers, and manage your local data. All processing happens in your browser.
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