4-year PhD Studentship: A realist process evaluation of a conservative care intervention embedded within the ‘Prepare for Kidney Care’ Randomised Controlled Trial

End-stage kidney disease (ESKD) places significant social and economic burden on healthcare systems worldwide. Improving access to dialysis can reduce preventable mortality, but there are questions around which patients benefit from dialysis, and how best to manage those who do not. Observational studies suggest quality and length of life are similar in older and/or comorbid adults who opt for dialysis versus conservative care, but high-quality evidence is limited [1]. Provision of dialysis or conservative care in this patient group varies considerably across NHS renal units, with marked variability in the quality and content of conservative care services.[2]

The University of Bristol’s Prepare for Kidney Care study (P4KC) is a pragmatic RCT that seeks to establish the clinical and cost-effectiveness of ‘preparation for dialysis’ versus a defined programme of conservative care called ‘Responsive Management’. The trial has pioneered use of methodological innovations to support recruitment and has a strong international following. With recruitment surpassing its half-way point, there is a unique opportunity to potentiate P4KC’s impact by investigating how Responsive Management works, in what contexts, and why. Realist evaluation methodology holds potential to explain P4KC’s findings, guide implementation, and explicate elements of Responsive Management that hold promise for future conservative care.

Aims and objectives

This project aims to evaluate delivery of Responsive Management across UK renal units, with a view to generating evidence-informed explanations of the P4KC RCT findings and identifying contextual factors likely to shape implementation.

This will be achieved by:

1. Generating hypotheses around the mechanisms of action and effects of Responsive Management, informed by existing evidence, theory, and stakeholder input;
2. Investigating contexts and mechanisms that support or hinder Responsive Management delivery, with a view to guiding future implementation.
3. Identifying the key ingredients underpinning how Responsive Management works, or elements that show promise for incorporation into future conservative care interventions.

Methodology

The project will draw on realist evaluation methodology [3], with scope for the successful candidate to adapt the approaches following familiarisation with the research context and training. The student will be fully supported in developing knowledge and skills in qualitative research, trials methodology, and evaluation of complex interventions.

The study objectives will be addressed using the following anticipated methods:

1. Hypotheses generation about intended effects and mechanisms of action of Responsive Management will be generated through: evidence syntheses of current conservative care approaches; interactive workshops with key professional and patient stakeholder, and semi-structured interviews with key informants involved in developing Responsive Management.
2. Ethnographic approaches will be used to generate a comprehensive understanding of how Responsive Management is delivered in practice, including factors that support, hinder, or change the intervention. Data will be synthesised from observations, surveys, interviews with healthcare professionals, and longitudinal case-studies of patients’ and relatives’/carers’ experiences of Responsive Management (captured through interviews and documentary analysis).
3. Findings from the ethnographic work will be considered alongside trial outcome data, to illuminate explanations for the contextual and mechanistic factors that influence Responsive Management’s effectiveness, or its components that hold promise in future efforts to improve conservative management of CKD.

How to apply for this project

This project will be based in Bristol Medical School - Population Health Sciences in the Faculty of Health Sciences at the University of Bristol.

Please visit the Faculty of Health Sciences website for details of how to apply