What is the role of doctors in respect of suspects with mental health and intellectual disabilities in police custody?

People with severe mental illness and intellectual disabilities are overrepresented in the criminal justice system worldwide and this is also the case in Ireland. Following Ireland's ratification of the United Nations' Convention on the Rights of People with Disabilities in 2018, there has been an increasing emphasis on ensuring access to justice for people with disabilities as in Article 13. For people with mental health and intellectual disabilities, this requires a multi-agency approach and a useful point of intervention may be at the police custody stage. Medicine has a key role to play both in advocacy and in practice. We suggest a functional approach to assessment, in practice, and list key considerations for doctors attending police custody suites. Improved training opportunities and greater resources are needed for general practitioners and psychiatrists who attend police custody suites to help fulfill this role.

Early Career Training in Addiction Medicine: A Qualitative Study with Health Professions Trainees Following a Specialized Training Program in a Canadian Setting

Background: There has been a notable deficiency in the implementation of addiction science in clinical practice and many healthcare providers feel unprepared to treat patients with substance use disorders (SUD) following training. However, the perceptions of addiction medicine training by learners in health professions have not been fully investigated. This qualitative study explored perceptions of prior training in SUD care among early-career trainees enrolled in Addiction Medicine fellowships and electives in Vancouver, Canada. Methods: From April 2015 - August 2018, we interviewed 45 early-career physicians, social workers, nurses, and 17 medical students participating in training in addiction medicine. We coded transcripts inductively using qualitative data analysis software (NVivo 11.4.3). Results: Findings revealed six key themes related to early-career training in addiction medicine: (1) Insufficient time spent on addiction education, (2) A need for more structured addictions training, (3) Insufficient hands-on clinical training and skill development, (4) Lack of patient-centeredness and empathy in the training environment, (5) Insufficient implementation of evidence-based medicine, and (6) Prevailing stigmas toward addiction medicine. Conclusion: Early clinical training in addiction medicine appears insufficient and largely focused on symptoms, rather than etiology or evidence. Early career learners in health professions perceived benefit to expanding access to quality education and reported positive learning outcomes after completing structured training programs.

Predictors and Outcomes for COVID-19 Re-Admissions in the Anticipate Cohort

Aims To describe readmissions of hospitalised patients with COVID-19, define predictors of readmission and explore the long term outcomes using the SF-12 score compared to patients who were not readmitted and those not hospitalised. Methods A single centre retrospective in North Inner-City Dublin. Recruitment was done through a COVID follow up clinic. Predictors of readmission and SF-12 scores at two timepoints post follow up at median 3 months and 12 months. Results Seventy (45%) participants were admitted, with a median age of 49.5 years (IQR 41.3-56.9), 36(51%) of whom were female. Unscheduled readmissions at ≤30 days in COVID-19 patients were 9(12.9%) and length of stay was four days (IQR 2-5). Readmissions were due to ongoing symptoms(n=9(64.3%)) or new complications(n=5(35.7%)). Mechanical ventilation and having symptoms of nausea and vomiting on index admission were predictive of readmission. (p=0.002). SF-12 scores at one year of readmitted patients were not different to patients who were never admitted at median one year follow up, p=.089. Conclusions Most readmissions were of short duration. Early follow up of patients post MV or who had nausea and vomiting on index admission should be prioritised. Wellbeing of readmitted patients was not different to those never hospitalised, at one year.

484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

Introduction

The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.

Methods

This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified.

Results

Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p < 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.

Conclusion

The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

The impact of green spaces on mental health in urban settings: a scoping review

BACKGROUND

Our planet is currently experiencing the largest wave of urban growth in history, with 55% of the world's population (4.2 billion people) currently living in urban areas, a figure set to rise to 70% by 2050. Primary care is the first point of treatment for most mental health disorders. Since the urban environment and health are intrinsically linked, it is useful to examine the effectiveness of Nature-Based Solutions in addressing mental health.

AIMS

The aim of this scoping review was to examine "How urban green spaces can improve mental health and wellbeing among patients attending general practice and primary care?"

METHODS

The scoping review framework comprised a five-stage process developed by Arksey and O'Malley.

RESULTS

Twenty-five studies were included in the review, mostly cross-sectional studies. A wide range of mental health outcomes were identified. Out of the 25 included studies, 23 showed positive associations between mental health and green space characteristics.

CONCLUSION

Our findings suggest that while green spaces are associated with positive mental health outcomes, most studies were cross-sectional in nature and provided limited evidence for association. Furthermore, the population samples used in most of the studies were taken from national survey data and were not specifically primary care patients. Further studies that assess primary care patients specifically are warranted.

Medical Students' Knowledge and Attitudes TowardsUniversal Access to Healthcare (UHC) Systems

Aim With the introduction of universal access to healthcare central to health policy in Ireland, this study aims to examine the attitudes of medical students to the implementation of such policy. Methods A cross sectional study of final year students on the MB degree programme at UCD School of Medicine was conducted. Students were asked to indicate the extent with which they agreed / disagreed with several statements using a Likert-scale (where 1=strongly disagree and 5=strongly agree). Results A total of 98(42%) of the 236 final year students completed the survey. The statements with which respondents most agreed were: "the GP's workload would increase" and "a UHC system is preferable to one in which only some patients have free access to certain services" (mean 4.3, SD 0.85 and mean 3.85, SD 1.05, respectively). The statements with which students most disagreed were: "it would be straightforward to introduce such a system in the practice(s) in which I have been on placement" and "under a UHC model, patients would receive quicker care" (mean 2.14, SD 0.91 and mean 2.29, SD 1.09 respectively). Conclusion The findings suggest that medical students are positively disposed to the introduction of UHC but have concerns regarding workload.

How does small group continuing medical education (CME) impact on practice for rural GPs and their patients, a mixed-methods study

Studies which report outcomes of continuing medical education (CME) interventions for rural general practitioners (GPs) are limited. This mixed methods study recruited GPs from four CME small group learning (SGL) tutor groups based in different rural locations in the Republic of Ireland. A two-hour teaching module on deprescribing in older patients was devised and implemented. Assessment of educational outcomes was via questionnaires, prescribing audits and qualitative focus groups. All GPs (n = 43) in these CME-SGL groups agreed to participate, 27 of whom (63%) self-identified as being in rural practice. Rural GPs were more likely to be male (56%), in practice for longer (19 years), and attending CME for longer (13 years). The questionnaires indicated learning outcomes were achieved knowledge increased immediately after the education, and was maintained 6 months later. Twenty-four GPs completed audits involving 191 patients. Of these, 152 (79.6%) were de-prescribed medication. In the qualitative focus groups, GPs reported sharing experiences with their peers during CME-SGL helped them to improve patient care and ensured that clinical practice is more consistent across the group. For rural GPs, CME-SGL involving discussion of cases and the practical implementation of guidelines, associated with audit, can lead to changes in patient care.

Hepatitis C virus infection in Irish drug users and prisoners - a scoping review

BACKGROUND

Hepatitis C infection is a major public health concern globally. In Ireland, like other European countries, people who use drugs (PWUD) and prisoners carry a larger HCV disease burden than the general population. Recent advances in HCV management have made HCV elimination across Europe a realistic goal. Engaging these two marginalised and underserved populations remains a challenge. The aim of this review was to map key findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWUD and prisoners.

METHODS

A scoping review guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey & O'Malley).

RESULTS

A total of 58 studies were identified and divided into the following categories; Epidemiology, Guidelines and Policy, Treatment Outcomes, HCV-related Health Issues and qualitative research reporting on Patients' and Health Providers' Experiences. This review identified significantly higher rates of HCV infection among Irish prisoners and PWUD than the general population. There are high levels of undiagnosed and untreated HCV infection in both groups. There is poor engagement by Irish PWUD with HCV services and barriers have been identified. Prison hepatology nurse services have a positive impact on treatment uptake and outcomes. Identified gaps in the literature include; lack of accurate epidemiological data on incident infection, untreated chronic HCV infection particularly in PWUD living outside Dublin and those not engaged with OST.

CONCLUSION

Ireland like other European countries has high levels of undiagnosed and untreated HCV infection. Collecting, synthesising and identifying gaps in the available literature is timely and will inform national HCV screening, treatment and prevention strategies.

Hepatitis C virus screening and treatment in Irish prisons from nurse managers' perspectives - a qualitative exploration

Background

Prisoners carry a greater burden of physical, communicable and psychiatric disease compared to the general population. Prison health care structures are complex and provide challenges and opportunities to engage a marginalised and poorly served group with health care including Hepatitis C Virus (HCV) screening, assessment and treatment. Optimising HCV management in prisons is a public health priority. Nurses are the primary healthcare providers in most prisons globally. Understanding the barriers and facilitators to prisoners engaging in HCV care from the perspectives of nurses is the first step in implementing effective strategies to eliminate HCV from prison settings. The aim of this study was to identify the barriers and facilitators to HCV screening and treatment in Irish prisons from a nurse perspective and inform the implementation of a national prison-based HCV screening program.

Methods

A qualitative study using focus group methodology underpinned by grounded theory for analysis in a national group of nurse managers (n = 12).

Results

The following themes emerged from the analysis; security and safety requirements impacting patient access, staffing and rostering issues, prison nurses’ skill set and concerns around phlebotomy, conflict between maintaining confidentiality and concerns for personal safety, peer workers, prisoners’ lack of knowledge, fear of treatment and stigma, inter-prison variations in prisoner health needs and health service delivery and priority, linkage to care, timing of screening and stability of prison life.

Conclusions

Prison nurses are uniquely placed to identify barriers and facilitators to HCV screening and treatment in prisoners and inform changes to health care practice and policy that will optimise the public health opportunity that incarceration provides.

Hepatitis C virus screening and treatment in Irish prisons from a governor and prison officer perspective - a qualitative exploration

BACKGROUND

Prisons are a key location to access Hepatitis C Virus (HCV) infected people who inject drugs (PWID). Prison health care structures are complex and optimising health care delivery to this high need, marginalised and underserved population remains challenging. Despite international guidelines recommending that prisons are a priority location for HCV screening and treatment levels of prisoner engagement in HCV care remain low. Competing priorities between security and healthcare is a key feature of prison health care. A collaborative approach to health care delivery in prisons can maximise the benefits for prisoners, staff and the wider community.

AIM

To identify the barriers and enablers to HCV screening and treatment in Irish prisons and inform the implementation of a HCV screening program within the Irish Prison Services (IPS).

METHODS

Qualitative study using focus group methodology underpinned by grounded theory.

RESULTS

The following themes emerged from the analysis: priority of safety and security, staffing and resources, concerns about personal risk, lack of knowledge, concerns around confidentiality, prisoners' fear of treatment and stigma, timing of screening, use of peer workers, in-reach hepatology and fibroscanning services. The primary role of prison security is to ensure the safety of staff and prisoners with a secondary but important supporting role in health care delivery. Maintaining adequate staffing levels and the provision of training and education were seen as priorities and impacted on prison officers' fear for personal safety and risk of HCV transmission. Opt-out screening and peer support workers had high levels of support among participants.

CONCLUSION

Upscaling HCV management in prisons requires an in-depth understanding of all barriers and facilitators to HCV screening and treatment. Engaging prison officers in the planning and delivery of health care initiatives is a key strategy to optimising the public health opportunity that prisons provides.

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.

Two birds with one stone: experiences of combining clinical and research training in addiction medicine

BACKGROUND

Despite a large evidence-base upon which to base clinical practice, most health systems have not combined the training of healthcare providers in addiction medicine and research. As such, addiction care is often lacking, or not based on evidence or best practices. We undertook a qualitative study to assess the experiences of physicians who completed a clinician-scientist training programme in addiction medicine within a hospital setting.

METHODS

We interviewed physicians from the St. Paul's Hospital Goldcorp Addiction Medicine Fellowship and learners from the hospital's academic Addiction Medicine Consult Team in Vancouver, Canada (N = 26). They included psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. Drawing on Kirkpatrick's model of evaluating training programmes, we analysed the interviews thematically using qualitative data analysis software (Nvivo 10).

RESULTS

We identified five themes relating to learning experience that were influential: (i) attitude, (ii) knowledge, (iii) skill, (iv) behaviour and (v) patient outcome. The presence of a supportive learning environment, flexibility in time lines, highly structured rotations, and clear guidance regarding development of research products facilitated clinician-scientist training. Competing priorities, including clinical and family responsibilities, hindered training.

CONCLUSIONS

Combined training in addiction medicine and research is feasible and acceptable for current doctors and physicians in training. However, there are important barriers to overcome and improved understanding of the experience of addiction physicians in the clinician-scientist track is required to improve curricula and research productivity.

Development and implementation of a 'Mental Health Finder' software tool within an electronic medical record system

BACKGROUND

In Ireland, as in many other healthcare systems, mental health service provision is being reconfigured with a move toward more care in the community, and particularly primary care. Recording and surveillance systems for mental health information and activities in primary care are needed for service planning and quality improvement.

AIMS

We describe the development and initial implementation of a software tool ('mental health finder') within a widely used primary care electronic medical record system (EMR) in Ireland to enable large-scale data collection on the epidemiology and management of mental health and substance use problems among patients attending general practice.

METHODS

In collaboration with the Irish Primary Care Research Network (IPCRN), we developed the 'Mental Health Finder' as a software plug-in to a commonly used primary care EMR system to facilitate data collection on mental health diagnoses and pharmacological treatments among patients. The finder searches for and identifies patients based on diagnostic coding and/or prescribed medicines. It was initially implemented among a convenience sample of six GP practices.

RESULTS

Prevalence of mental health and substance use problems across the six practices, as identified by the finder, was 9.4% (range 6.9-12.7%). 61.9% of identified patients were female; 25.8% were private patients. One-third (33.4%) of identified patients were prescribed more than one class of psychotropic medication. Of the patients identified by the finder, 89.9% were identifiable via prescribing data, 23.7% via diagnostic coding.

CONCLUSIONS

The finder is a feasible and promising methodology for large-scale data collection on mental health problems in primary care.

Cocaine use in Young Adults: Correlation with Early Onset Cannabis, Alcohol and Tobacco Use

There is ongoing debate regarding the relationship between early tobacco, alcohol and cannabis use and later cocaine abuse. We utilised data from two Irish national general population surveys. Of the 1,897 young adult participants, the prevalence of lifetime use was as follows: tobacco 62%, alcohol 96%, cannabis 31% and cocaine 7.0%. Logistic regression analysis indicated that being single, earlier age of first alcohol use, and history of cannabis use were significant independent predictors of lifetime use of cocaine. The substance use route to cocaine use in this Irish sample is quite typical of that seen internationally. Those who commence alcohol use in the early teenage years are more likely to use cocaine subsequently, even after controlling for early onset cannabis use and other socio-demographic characteristics. This suggests that policies which delay age of first drinking may possibly also curtail cocaine use.

70,489 primary care encounters: retrospective analysis of morbidity at a primary care centre in Ireland

BACKGROUND

While considerable changes are happening in primary care in Ireland and considerable potential exists in intelligence derived from practice-based data to inform these changes, relatively few large-scale general morbidity surveys have been published.

AIMS

To examine the most common reasons why people attend primary care, specifically 'reasons for encounter' (RFEs) among the general practice population and among specific demographic groups (i.e., young children and older adults).

METHODS

We retrospectively examined clinical encounters (which had a diagnostic code) over a 4-year time period. Descriptive analyses were conducted on anonymised data.

RESULTS

70,489 RFEs consultations were recorded (mean 13.53 recorded RFEs per person per annum) and consultations involving multiple RFEs were common. RFE categories for which codes were most commonly recorded were: 'general/unspecified' (31.6 %), 'respiratory' (15.4 %) and 'musculoskeletal' (12.6 %). Most commonly recorded codes were: 'medication renewal' (6.8 %), 'cough' (6.6 %), and 'health maintenance/prevention' (5.8 %). There was considerable variation in the number of RFEs recorded per age group. 6239 RFEs (8.9 %) were recorded by children under 6 years and 15,295 RFEs (21.7 %) were recorded by adults aged over 70. RFEs recorded per calendar month increased consistently through the study period and there was a marked seasonal and temporal variation in the number of RFEs recorded.

CONCLUSIONS

Practice databases can generate intelligence on morbidity and health service utilisation in the community. Future research to optimise diagnostic coding at a practice level and to promote this activity in a more representative sample of practices is a priority.

Treatment outcome for adolescents abusing alcohol and cannabis: how many 'reliably improve'?

Alcohol and cannabis are the primary substances contributing to referrals of adolescents to substance abuse treatment services. Their outcome has not been examined in Ireland. A three month follow-up was conducted in an outpatient adolescent treatment program. We followed up 35 high risk users of alcohol and 55 high risk users of cannabis. Although the high risk drinkers achieved a significant reduction in median number of days drinking (p = 0.004), only four (11 %) were abstinent at follow up. A further five (14%) achieved a reliable reduction in days of drinking. The high risk cannabis users demonstrated a significant drop in median days of use (p < 0.001), although only six (11%) were abstinent at follow up. A further 20 (36%) achieved a reliable reduction in days of use. Calculation of reliable change allows examination of outcomes which fall short of the elusive goal of abstinence.

Educational interventions: equipping general practice for youth mental health and substance abuse. A discussion paper

BACKGROUND

Youth mental health issues and substance abuse are important causes of morbidity and mortality in Ireland. General practice is a frequent point of contact for young people, however, reluctance amongst this population group to disclose mental health issues and a lack of confidence amongst GPs in dealing with them have been reported. Focussed training interventions with formal evaluation of their acceptability and effectiveness in achieving learning, behavioural change and impact on clinical practice are needed.

AIMS

This paper aims to examine the literature on general practice in youth mental health, specifically, factors for an educational intervention for those working with young people in the community.

METHODS

This review paper was carried out by an online search of PubMed on the recent literature on mental health and on educational interventions for health care workers in primary care.

RESULTS

A number of papers describing educational interventions for GPs and primary care workers were found and analysed. Key areas to be addressed when identifying and treating mental health problems were prevention, assessment, treatment, interaction with other services and ongoing support. Important elements of an educational intervention were identified.

DISCUSSION

Several barriers exist that prevent the identification and treatment of these problems in primary care. An educational intervention should help GPs address these issues. Any intervention should be rigorously evaluated.

CONCLUSION

With the shift in services to the community in Irish health policy, the GP with appropriate training could take the lead in early intervention in youth mental health and addiction.

Primary care teams in Ireland: a qualitative mapping review of Irish grey and published literature

INTRODUCTION

The Irish government published its primary care strategy, Primary Care: A New Direction in 2001. Progress with the implementation of Primary care teams is modest. The aim of this paper is to map the Irish grey literature and peer-reviewed publications to determine what research has been carried out in relation to primary care teams, the reform process and interdisciplinary working in primary care in Ireland.

METHODS

This scoping review employed three methods: a review of Web of Science, Medline and Embase databases, an email survey of researchers across academic institutions, the HSE and independent researchers and a review of Lenus and the Health Well repository.

RESULTS

N = 123 outputs were identified. N = 14 were selected for inclusion. A thematic analysis was undertaken. Common themes identified were resources, GP participation, leadership, clarity regarding roles in primary care teams, skills and knowledge for primary care team working, communication and community.

CONCLUSION

There is evidence of significant problems that disrupt team formation and functioning that warrants more comprehensive research.

Does eliminating fees at point of access affect Irish general practice attendance rates in the under 6 years old population? A cross sectional study at six general practices

With the introduction of free point of access GP care for children aged under six imminent, we sought to determine consultation rates among this group. We interrogated data from practice management systems at six general practices (total patient population 27080). A total of 1931 children aged under six were responsible for 5814 surgery consultations. The mean annual consultation rate was 3.01; 4.91 for GMS' patients, 5.07 for 'Doctor Visit' patients and 2.03 for private patients. Our findings suggest the introduction of free GP care for children under six will considerably increase GP consultations. We also highlight the value of routinely collected general practice data in facilitating health services planning. We estimate that there will be an additional 750,000 GP consultations annually.

Paediatric diabetes: information-seeking behaviours of families

The Internet provides patients and their families with ready access to on-line health related information. However, this information is not always accurate, understandable or provided by health professionals or advocacy groups. One hundred children with Type 1 diabetes mellitus, or their parents, attending a paediatric diabetes clinic during September to November 2011 were invited sequentially to participate in this questionnaire-based survey of Internet use in searching for diabetes-related information. Sixty-seven (67%) returned completed anonymised questionnaires: 36/67 (53%) were categorised as socio-economic groups C1/C2. Of the 67 families who returned completed questionnaires, 64 (96%) had a home computer and 62 (93%) had home Internet access; 27 (40%) rarely, and 40 (60%) frequently, searched on-line for diabetes-related information. Key search terms were not provided by respondents. There appears to be considerable internet use in seeking health related information for children with Type 1 diabetes mellitus. Clinicians should make efforts to direct patients and their families to websites that present accurate and current information.

Food and beverage advertising during children's television programming

BACKGROUND

Increasing prevalence of overweight and obese children in developed countries poses a substantial threat to long-term health. One well-described factor is the amount of time spent watching television, with exposure to food advertising a known influence on food preferences and consumption patterns.

AIMS

Following recent formulation of new rules regarding advertising of food during children's programming, we sought to examine the advertising content in children-specific television broadcasts on Irish television.

METHODS

Advertisement content analysis for 5 weekdays of children-specific television broadcasting from 0700 to 1700 hours on Irish television was performed. Data were coded and transferred to SPSS for analyses. Food and beverage advertisements were coded based on type of product, nutritional content, intended age group and outcome.

RESULTS

322 advertisements were broadcast during the recording period. 31 % (n = 101) of advertisements related to food or beverage products with 66.3 % (n = 68) of food advertisements being for foods that should be eaten in moderation. The most frequently recorded food advertisement was for fast food products (27.3 %, n = 24), followed by sweets/candy (21.6 %, n = 19) and dairy products (17.0 %, n = 15). The most frequently recorded beverage advertisement was for natural orange juices (46.2 %, n = 6). 54.7 % (n = 176) of advertisements were adult specific with 27.3 % (n = 88) being children specific. All food and beverage advertisements were associated with a positive outcome (n = 322).

CONCLUSIONS

These results demonstrate that food and beverages depicted in advertisements during children's programming are predominantly unhealthy foods with high salt and sugar contents. The findings from this study again highlight the ongoing need for new rules regarding food advertising in children's programming.

General practice career intentions among graduate-entry students: a cross-sectional study at Ireland's newest medical school

Increased care provision and clinical activity in General Practice in Ireland will have important manpower implications. Recent developments in medical education policy including the introduction of graduate-entry medical degree programmes may help address this issue. The aim of this study was to determine GP career intentions among students on an Irish graduate-entry medical degree programme and to identify factors that influence these. An electronic cross-sectional study of students at University of Limerick Graduate-Entry Medical School (UL-GEMS) was undertaken. We received 139 replies (78% response rate). 41 (29%) reported GP was their current preferred career choice, while 29 (19%) reported it was their preferred career choice on entry to medical school. This first study to present data on GP career intentions among graduate-entry students in Ireland highlights the specialty as a popular preferred career choice among students, both on entry to, and during medical school. The study also identifies factors which are likely to be important in determining career intentions. Further research to examine this issue at other graduate-entry medical schools in Ireland and to determine whether our findings are pursued over time amongst graduates is a priority.

Care of type 2 diabetes in unresourced general practice: current practice in the Mid-West

It is estimated that 4.5% of the Irish population have type 2 diabetes. The HSE intends to move the care of uncomplicated type 2 diabetes to General Practice (GP). The study reviewed current General Practice diabetes care in the Irish Mid-West. The files of randomly selected patients from 12 GP teaching practices attached to the University of Limerick were audited. 842 patients were identified (62% male, 38% female). The mean age was 66 years. 75% were GMS patients. A practice protocol was used in 71% of patients. Average Cholesterol (4.3 mmol/l), creatinine (85.3 mmol/l), HbA1c (56.7 mmol/mol) and systolic blood pressure (SBP) (134 mmHg) measurements were well documented and controlled. However the rates of and mean intervals for foot review (60.2%), BMI measurement (52.3%), retinopathy screening (62.0%) and influenza vaccination (63.0%) were unacceptably low. Current management of type 2 diabetes in unresourced general practices is suboptimal although some biochemical parameters are well controlled.

Are Irish adult general practice consultation rates as low as official records suggest? A cross sectional study at six general practices

Accurate data on primary care activity is key to health services planning and reconfiguration. Official data estimate general practice adult consultation rates to be 3.2 visits annually, based on patient self reports. We aim to estimate the consultation rate using practice based data and compare this to official estimates. We interrogated six general practices' information systems and estimated consultation rates based on practice, telephone, domiciliary and out of hours consultations by patients aged 18 years or older. The study population (20,706 patients) was representative of the national population in terms of age and GMS status. The mean consultation rate was 5.17, though this was higher among GMS-eligible patients and among older age groups. Estimates of consultation rates derived from practice based data are likely to be higher than that derived from other approaches. Using multiple sources of data will enhance accuracy of workload estimates and this will benefit service planning.

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice

BACKGROUND

Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.

AIMS

This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.

METHODS

The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified 'Delphi-facilitated' consensus among the group members.

RESULTS

The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.

CONCLUSIONS

Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.

Structured care of diabetes in general practice: a qualitative study of the barriers and facilitators

This qualitative study explored general practitioner's and practice nurse's perceptions of barriers and facilitators to the proposed transfer of diabetes care to general practice. Qualitative data were collected through five focus groups. Participants included GPs (n = 55) and practice nurses (n = 11) representing urban (44%), rural (29%) and mixed (27%) practices, in the Irish Mid-West region. Barriers and facilitators were mentioned 631 times (100%). Barriers were mentioned 461 times (73%), facilitators 170 times (27%). The most frequently identified barriers were lack of financial incentive (119/631; 19%), lack of access to secondary resources (93/631; 15%), lack of staff and increased workload (59/631; 9%) and time constraints (52/631; 8%). Identified facilitators were access to secondary care (49/631;7.8%), the holistic nature of general practice and continuity of care (48/631;7.6%). Although many are enthusiastic, there remains significant reluctance among GPs and practice nurses to take responsibility for diabetes care without addressing these barriers.

An evidence-based assessment of primary care needs in an economically deprived urban community

BACKGROUND

As healthcare and longevity improve and fertility rates decline, we see a demographic shift towards a predominantly elderly population. Because ageing brings its own physiological changes and complications, the need arises for practical and feasible approaches in providing the healthcare required by this population. With government strategy promoting enhanced community-based healthcare, the development of primary care infrastructure should reflect population needs.

AIMS

To describe the profile of older patients attending a general practice in an underprivileged urban setting, specifically initial medical presentation, referrals for secondary care, and the medicines prescribed to them. To thereby enhance our understanding of the primary care requirements of elderly people in this setting.

METHODS

The anonymised records of an older patient cohort (n=427, age>55 years) that presented to a General Practice over a 12-month period were retrospectively analysed to determine the nature of the clinical encounters, subsequent referral patterns and drugs prescribed.

RESULTS

There were 3,448 discrete clinical encounters (mean=8.0 per patient), predominantly for respiratory conditions, leading to 401 issued scripts and to 216 patients being referred for secondary care. Women were referred more often than men. There was a notable need for specialised dietary advice and drug prescribing was often complex.

CONCLUSION

This study provides evidence of primary care needs in an economically deprived area of an Irish city highlighting the complexity of associated prescribing and secondary care referrals in this setting.

Towards vertical integration in general practice education: literature review and discussion paper

BACKGROUND

Medical education policy in Ireland has enabled an increase in undergraduate and postgraduate education activity in general practice. Internationally, 'vertical integration in general practice education' is suggested as a key strategy to support the implementation of this policy development.

AIMS

To review the emerging literature on vertical integration in GP education, specifically to define the concept of 'vertical integration' with regard to education in general practice and to describe its benefits and challenges.

METHODS

We searched 'Pubmed', 'Academic Search Complete', 'Google', and 'MEDLINE' databases using multiple terms related to 'vertical integration' and 'general practice education' for relevant articles published since 2001. Discussion papers, reports, policy documents and position statements were identified from reference lists and retrieved through internet searches.

RESULTS

The key components of 'vertical integration' in GP education include continuous educational pathway, all stages in GP education, supporting the continuing educational/professional development needs of learners at each stage and effective curriculum planning and delivery. Many benefits (for GPs, learners and the community) and many challenges (for GPs/practices, learners and GPs in training) have been described. Characteristics of successful implementation include role sharing and collaborative organisational structures.

CONCLUSIONS

Recent developments in medical education in Ireland, such as the increase in medical school clinical placements in general practice and postgraduate GP training and the introduction of new competence assurance requirements offer an important opportunity to further inform how vertical integration can support increased educational activity in general practice. Describing this model, recognising its benefits and challenges and supporting its implementation in practice are priorities for medical education in Ireland.

Primary care support for youth mental health: a preliminary evidence base for Ireland's Mid-West

BACKGROUND

Mental and substance use disorders are leading causes of morbidity. Prevention/treatment amongst young people are global health priorities. International data have highlighted primary care and general practice as important in addressing these.

AIMS

Survey of 128 physicians (GPs) in Ireland's Mid-West (Counties Limerick, Clare, North Tipperary) to document the spectrum of youth mental health problems, describe strategies adopted by GPs in dealing with these, identify barriers (perceived by GPs) to effective care of young mental health patients and collate GP proposals for improved care of this cohort.

METHODS

Self-administered questionnaire on physician and practice demographics, case management and barriers to care in youth mental health.

RESULTS

Thirty-nine GPs (31 %) responded. Mental health and family conflict represented the most frequent reasons why young people attended GPs. Depression, anxiety, family conflict, suicidal thoughts/behaviour, and attention deficit hyperactivity disorder (ADHD) were the most common issues followed by substance abuse and antisocial behaviours. GP referral practices for young people with mental/substance use disorders varied, with distinctions between actual and preferred management due to insufficient access to dedicated youth services and training. GPs stated need for improved access to existing services (i.e., Psychiatry, counseling/psychology, social/educational interventions). A number of GPs surveyed were located, or provided care, in Limerick's 'Regeneration Areas'. Young people in these areas predominantly attended GPs due to mental/substance use issues and antenatal care, rather than acute or general medical problems.

CONCLUSIONS

GPs play an important role in meeting youth mental health needs in this region and, in particular, in economically deprived urban areas.

Can general practice help address youth mental health? A retrospective cross-sectional study in Dublin's south inner city

AIMS

With general practice potentially having an important role in early intervention of mental and substance use disorders among young people, we aim to explore this issue by determining the prevalence of psychological problems and general practice/health service utilization among young people attending general practice.

METHODS

A retrospective cross-sectional study of patients attending three general practices in Dublin city.

RESULTS

Among a sample of young people (mostly women, 44% general medical services (GMS) eligible), we observed considerable contact with general practice, both lifetime and for the 2 years of the study. The mean consultation rate was 3.9 consultations in 2 years and psychosocial issues (most commonly stress/anxiety and depression) were documented in 35% of cases. Identification of psychosocial issues was associated with GMS eligibility, three or more doctor consultations, and documentation of smoking and drinking status.

CONCLUSIONS

Psychosocial issues are common among young people attending general practice and more work on their epidemiology and further identification in general practice are advocated.