An audit of the Irish National Intellectual Disability Database

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

BACKGROUND

Multicentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and resource-constrained contemporary healthcare settings. There are little data on what facilitates the successful implementation of multicentre audits. As healthcare environments are complex sociocultural organisational environments, implementing multicentre audits within them is likely to be highly context dependent.

OBJECTIVE

We aimed to examine factors that were influential in the implementation process of multicentre comparative audits within healthcare contexts-what worked, why, how and for whom?

METHODS

A realist review was conducted in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards reporting standards. A preliminary programme theory informed two systematic literature searches of peer-reviewed and grey literature. The main context-mechanism-outcome (CMO) configurations underlying the implementation processes of multicentre audits were identified and formed a final programme theory.

RESULTS

69 original articles were included in the realist synthesis. Four discrete CMO configurations were deduced from this synthesis, which together made up the final programme theory. These were: (1) generating trustworthy data; (2) encouraging audit participation; (3) ensuring audit sustainability; and (4) facilitating audit cycle completion.

CONCLUSIONS

This study elucidated contexts, mechanisms and outcomes influential to the implementation processes of multicentre or national comparative audits in healthcare. The relevance of these contextual factors and generative mechanisms were supported by established theories of behaviour and findings from previous empirical research. These findings highlight the importance of balancing reliability with pragmatism within complex adaptive systems, generating and protecting human capital, ensuring fair and credible leadership and prioritising change facilitation.

Predictors of access to healthcare professionals for people with intellectual disability in Ireland

The Irish National Intellectual Disability Database is updated annually and in 2017 contained records for nearly 22,000 persons aged 15 years and over. Information was extracted on the contacts each person had with one of eight health professionals in the years 2007, 2012 and 2017. Over these years, there was an increase in the number of people in contact with any professional or with four and more professionals. Nevertheless, the people less likely to have contact were those with milder forms of intellectual disability, persons living with family carers or independently and those linked to smaller provider agencies. By contrast, the odds of people with more severe disability in residential settings were up to eight times greater for having contact with four or more different professionals. As demand for healthcare grows due to increased longevity and service models shift to the community, redeployment of existing professional resources will be needed along with a review of the skill mix.

Family carers of people with intellectual disabilities in Ireland: Changes over 10 years

Data were obtained on nearly 20,000 Irish children and adults living in various family care arrangements in 2007, 2012, and 2017. Over 10 years, the percentage increase in adult persons living with family carers was three times higher than the rise in the general population, with people aged 50 years and over having the highest proportional increase. Also a greater number of persons aged 40-49 group continued to live with both parents in 2017 (47%) compared to 2007 (33%). However, there was marked variation across the nine Community Health Organization areas in the proportions of adults living with family carers (from 49% to 62%). In the coming decades, increased provision will be required in both the quantum and type of supports provided to families so as to sustain their caring role but ensuring equity of provision nationally will be a major challenge.

A case-study of policy change in residential service provision for adult persons with intellectual disability in Ireland

In Europe, many people with intellectual disabilities continue to live in congregated settings. In 2012, Ireland formally introduced a resettlement policy with people moving to live in more personalised arrangements. This longitudinal country case-study aimed to monitor the implementation of this policy and the intra-country variations that arose using the records maintained in the National Intellectual Disability Database. Details of over 4,000 people living in congregated settings were examined in 2007 and again in 2012 and 2017. In addition, people who moved from such settings from 2007 onwards were tracked and the number of new admissions to them was estimated over the 10-year period. Overall there was nearly a 30% drop in the numbers of people in congregated settings but the reductions varied markedly across the country and by 2017 the disparity was greater than in 2007. Also by 2017 persons aged over 55 years were eight times more likely to be accommodated in congregated settings. The case-study illustrates the value of a longitudinal dataset for monitoring policy implementation across a diversity of provider organisations and administrative areas.

The prevalence of intellectual disability: A comparison of national census and register records

BACKGROUND

International prevalence rates for intellectual disability vary widely with estimates often based on samples. In Ireland people with an intellectual disability are identified in the national census. Moreover, a national register of people receiving or requiring intellectual disability services is maintained and updated annually.

AIMS

The prevalence rates from the census were contrasted with those from the register along with variations in prevalence across the 26 counties of Ireland.

METHODS

2011 and 2016 Census of Population prevalence per 1000 for children (aged 5-19 years) and adults (20 years and over) stratified by the 26 countries were contrasted with similar prevalence in the national register. Publically available data from the 2011 census in Northern Ireland and Scotland were obtained.

RESULTS

The Irish census identified nearly twice as many children and adults than were on the national register. Prevalence rates also varied across the 26 counties; more so on the register than the census. The Irish census had lower prevalence rates than Northern Ireland but higher than Scotland.

CONCLUSIONS

Determining the prevalence of intellectual disability is challenging due to variations in terminology. A national register has advantages over reliance on census data for service planning.

Irish persons with intellectual disability moving from family care to residential accommodation in a period of austerity

BACKGROUND

Ireland has a growing population of adult persons living with family carers, thereby increasing the demand for residential places. Simultaneously, government policy aimed to reprovision residents living in congregated settings but at a time when funding was curtailed due to the economic crisis. This study examines the movements of people into and among three types of residential options between 2009 and 2014.

METHOD

A cohort of 20,163 persons recorded on the National Intellectual Disability Database in 2009 was identified and tracked to the 2014 database.

RESULTS

An estimated 200 persons per annum (@1.6% of those living with families) moved from family care although the number of places available nationally fell by 9%. Moreover, transfers of existing residents into vacated places tended to exceed those from families.

CONCLUSIONS

More people will have to continue living with their families and for longer if funding for new places remains curtailed.

Day Service Provision for People with Intellectual Disabilities: A Case Study Mapping 15-Year Trends in Ireland

BACKGROUND

Day services for people with intellectual disabilities are experiencing a global paradigm shift towards innovative person-centred models of care. This study maps changing trends in day service utilization to highlight how policy, emergent patterns and demographic trends influence service delivery.

METHODS

National intellectual disability data (1998-2013) were analysed using WINPEPI software and mapped using QGIS Geographic Information System.

RESULTS

Statistically significant changes indicated fewer people availing of day services as a proportion of the general population; more males; fewer people aged <35; a doubling in person-centred plans; and an emerging urban/rural divide. Day services did not change substantially and often did not reflect demand.

CONCLUSIONS

Emergent trends can inform future direction of disability services. Government funds should support individualized models, more adaptive to changing trends. National databases need flexibility to respond to policy and user demands. Future research should focus on day service utilization of younger people and the impact of rurality on service availability, utilization, quality and migration.

Moving from family care to residential and supported accommodation: national, longitudinal study of people with intellectual disabilities

Abstract A cohort of nearly 11,000 persons was traced over 8 years to determine those who had moved from family care and those who had remained. The majority (85%) continued to live with families, and, for two thirds (67%), no future move was deemed necessary. The 2 main predictors of moving were as follows: A need had been previously recorded and the family had used out-of-home respite services during the 8 years. However, just one quarter of those identified as needing to move had done so in the 8 years. Conversely, no prior indication of need had been recorded for two thirds of people who had moved in this period. The complexities of assessing need and equitably meeting demands are discussed.

Access to respite breaks for families who have a relative with intellectual disabilities: a national survey

AIMS

This paper reports the findings of a national study of the variations in the provision and correlates of respite breaks to families. Background.  Internationally, respite breaks are a major support service to family carers, demand for which often exceeds supply for persons with an intellectual disability. Hence, the length of breaks available to families has to be rationed. Nurses are often involved in such decisions.

METHOD

National data on the use of respite breaks by over 4000 families in a full calendar year (2008) were analysed to examine the variation within the Republic of Ireland on two indicators: namely the proportion of carers who had any access to breaks and the median number of days they had received.

FINDINGS

Striking differences across health service areas were found on both indicators of usage. These were not solely attributable to the availability of provision but also reflected variations in the criteria local services used to allocate places. However, those persons with more severe disabilities were given priority, whereas carer characteristics were not a major influence. Contact with social workers and community nurses also increased the likelihood of carers receiving respite breaks.

CONCLUSION

Intra-country comparisons of service delivery should assist planners in creating more equitable access to respite breaks and the development of more explicit eligibility criteria for their use. Nurses are well placed to lead on this.