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Wallace E, Revie L, Schneider D, Mais D, Sharland E. Thematic analysis of Prevention of Future Death reports for suicide: January 2021 to October 2022. BMJ Ment Health 2024; 27:1-7. [PMID: 38657975 PMCID: PMC11043700 DOI: 10.1136/bmjment-2023-300804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 03/13/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Suicide prevention remains a high priority topic across government and the National Health Service (NHS). Prevention of Future Death (PFD) reports are produced by coroners to highlight concerns that should be addressed by organisations to prevent future deaths in similar circumstances. OBJECTIVE This research aimed to understand themes from concerns raised in PFD reports for deaths from suicide to inform future policies and strategies for preventing suicide. METHODS We employed a retrospective case series design to analyse PFD reports categorised as suicide using qualitative inductive thematic analysis. Primary themes and subthemes were extracted from coroners' concerns. Following theme extraction, the number of concerns coded to these themes across reports and the frequency of recipient organisation being named as addressee on these reports were assessed as primary outcomes. FINDINGS 12 primary themes and 83 subthemes were identified from 164 reports (4% of all available reports). The NHS was the most frequent recipient of these reports, followed by government departments. Coroners raised issues around processes within or between organisations and difficulties accessing services. The most common concerns fell under the primary theme 'processes' (142 mentions), followed by 'access to services' (84 mentions). The most frequent subthemes were 'current training not adequate' (38 mentions) and 'inadequate communication between services' (35 mentions). CONCLUSIONS Our results specify areas where review, improvement and policy development are required to prevent future suicide deaths occurring in similar circumstances. CLINICAL IMPLICATIONS These themes highlight concerns across current care and service provision where reform is required for suicide prevention.
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Affiliation(s)
- Emma Wallace
- Data and Analysis for Social Care and Health Division, Office for National Statistics, Newport, UK
| | - Lauren Revie
- Data and Analysis for Social Care and Health Division, Office for National Statistics, Newport, UK
| | - Dorothee Schneider
- Data and Analysis for Social Care and Health Division, Office for National Statistics, Newport, UK
| | - David Mais
- Data and Analysis for Social Care and Health Division, Office for National Statistics, Newport, UK
| | - Emma Sharland
- Data and Analysis for Social Care and Health Division, Office for National Statistics, Newport, UK
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O' Reilly M, Wallace E, Merghani K, Conlon B, Breathnach O, Sheehan E. Trauma Assessment Clinic: A virtual fracture clinic model that delivers on its PROMise! J Telemed Telecare 2024; 30:579-588. [PMID: 35285739 DOI: 10.1177/1357633x221076695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of virtual fracture clinics across the United Kingdom and Ireland is growing and have been shown in an increasing number of studies to be safe, cost-effective and associated with good functional outcomes and patient satisfaction rates for certain fracture types. Initially pioneered at Glasgow Royal Infirmary, many centres have adopted similar templates, or variations of, and the overall aim of this study was to assess functional outcomes and injury recovery satisfaction rates of patients discharged directly following review in a specific virtual fracture clinic model known as the Trauma Assessment Clinic (TAC). METHODS A prospective observational study was carried out of paediatric (aged <17 years) and adult (aged >17 years) patients, with the five most commonly observed fracture types, who were discharged directly following review at the TAC in a single hospital centre over a 12 month period from January to December 2018. Primary and secondary outcomes were assessed via telephone administered questionnaires and patient reported outcome measures (PROMs). RESULTS A total of 198 patients were included in the study (n = 98 paediatric and n = 100 adult). Overall, 192 (97%) patients or parents/guardians of patients stated that they either strongly agreed (n = 148, 74.9%) or agreed (n = 44, 22.1%) that they were satisfied with their own or their child's recovery from their injury at a median follow-up of 9 months post direct discharge from the TAC. Adult patients had an EQ-5D-5L index median value of 1 (range 0-1), an EQ-VAS median of 87 (range 0-100), a QuickDASH median score of 0 (range 0-100) and a median LEFS of 80 (range 0-80). CONCLUSION The virtual management of trauma patients via the TAC model is a safe and patient-centred approach to treating certain injuries and fracture patterns. This study reports excellent patient reported outcome measures and patient injury recovery satisfaction rates. The use of current available technology in tandem with up-to-date best clinical practice and guidelines play a central role in this novel care pathway.
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Affiliation(s)
- Marc O' Reilly
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Khalid Merghani
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Breda Conlon
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Oisin Breathnach
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
| | - Eoin Sheehan
- Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital, Tullamore, Ireland
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Brannigan R, Hughes JE, Moriarty F, Wallace E, Kirke C, Williams D, Bennett K, Cahir C. Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions. J Clin Med 2024; 13:323. [PMID: 38256457 PMCID: PMC10816937 DOI: 10.3390/jcm13020323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital. METHODS Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy). RESULTS In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission. CONCLUSION There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.
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Affiliation(s)
- Ross Brannigan
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - John E. Hughes
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland;
| | - Emma Wallace
- Department of General Practice, University College Cork, T12 R229 Cork, Ireland;
| | - Ciara Kirke
- National Quality and Patient Safety Directorate at Health Service Executive, D08 W2A8 Dublin, Ireland;
| | - David Williams
- Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland;
- Department of Geriatric and Stroke Medicine Beaumont Hospital, D05 E840 Dublin, Ireland
| | - Kathleen Bennett
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
| | - Caitriona Cahir
- School of Population Health, RCSI University of Medicine and Health Sciences, D02 YN77 Dublin, Ireland; (R.B.); (K.B.)
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Shahid F, Doherty A, Wallace E, Schmiedl S, Alexander GC, Dreischulte T. Prescribing cascades in ambulatory care: A structured synthesis of evidence. Pharmacotherapy 2024; 44:87-96. [PMID: 37743815 DOI: 10.1002/phar.2880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/04/2023] [Accepted: 06/23/2023] [Indexed: 09/26/2023]
Abstract
The strength of evidence for specific ambulatory care prescribing cascades, in which a marker drug is used to treat an adverse event caused by an index drug, has not been well characterized. To perform a structured, systematic, and transparent review of the evidence supporting ambulatory care prescribing cascades. Ninety-four potential prescribing cascades identified through a previously published systematic review. Systematic search of the literature to further characterize prescribing cascades. (1) Grading of evidence based on observational studies investigating associations between index and marker drugs, including: Level I-strong evidence [i.e. multiple high-quality studies]; Level II-moderate evidence [i.e. single high-quality study]; Level III-fair evidence [no high-quality studies but one or more moderate-quality studies]; and Level IV-poor evidence [other]. (2) Listing of the adverse event associated with the index drug in the product's United States Food and Drug Administration (FDA) label. (3) Synthesis of the evidence supporting mechanisms linking index drugs and associated adverse events. Of 99 potential cascades, 94 were supported by one or more confirmatory observational studies and were therefore included in this review. The 94 cascades related to 30 types of adverse drug reactions affecting 10 different anatomic/physiologic systems and were investigated by a total of 88 confirmatory studies, including prescription sequential symmetry analysis (n = 51), cohort (n = 30), and case-control (n = 7) studies. Overall, the evidence from observational studies was strong for 18 (19.1%) prescribing cascades, moderate for 61 (64.9%), fair for 13 (13.8%), and poor for 2 (2.1%). Although the evidence supporting mechanisms that link index drugs and associated adverse events was variable, FDA labels included information about the adverse event associated with the index drug for most (n = 86) but not all of the 94 prescribing cascades. Although we identified 18 of 94 prescribing cascades supported by strong clinical evidence and most adverse events associated with index drugs are included in FDA label, the evidentiary basis for prescribing cascades varies, with many requiring further evidence of clinical relevance.
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Affiliation(s)
- Faiza Shahid
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Ann Doherty
- Department of General Practice, University College Cork, Cork, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
| | - Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - G Caleb Alexander
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Munich, Germany
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Waldron C, Hughes J, Wallace E, Cahir C, Bennett K. Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review. HRB Open Res 2023; 5:53. [PMID: 38283368 PMCID: PMC10811420 DOI: 10.12688/hrbopenres.13580.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/30/2024] Open
Abstract
Background Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required.A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version.The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.
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Affiliation(s)
- Catherine Waldron
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - John Hughes
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - Caitriona Cahir
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - K. Bennett
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
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O'Brien E, Walsh A, Boland F, Collins C, Harkins V, Smith SM, O'Herlihy N, Clyne B, Wallace E. GP preferences for, access to, and use of evidence in clinical practice: a mixed-methods study. BJGP Open 2023; 7:BJGPO.2023.0107. [PMID: 37442591 DOI: 10.3399/bjgpo.2023.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 06/11/2023] [Accepted: 06/16/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND GPs aim to provide patient-centred care combining clinical evidence, clinical judgement, and patient priorities. Despite a recognition of the need to translate evidence to support patient care, barriers exist to the use of evidence in practice. AIM To ascertain the needs and preferences of GPs regarding evidence-based guidance to support patient care. The study also aimed to prioritise content and optimise structure and dissemination of future evidence-based guidance. DESIGN & SETTING This was a convergent parallel mixed-methods study in collaboration with the national GP professional body in the Republic of Ireland (Irish College of General Practitioners [ICGP]). Quantitative and qualitative findings were integrated at the interpretive level. METHOD A national GP survey was administered via the ICGP (December 2020) and seven GP focus groups were undertaken (April-May 2021). RESULTS Of 3496 GPs, a total of 509 responders (14.6%) completed the survey and 40 GP participants took part in focus groups. Prescribing updates, interpretation of test results, chronic disease management, and older person care were the preferred topics for future evidence-based guidance. GPs reported that they required rapid access to up-to-date and relevant evidence summaries online for use in clinical practice. Access to more comprehensive reviews for the purposes of continuing education and teaching was also a priority. Multimodal forms of dissemination were preferred to increase uptake of evidence in practice. CONCLUSION GPs indicated that rapid access to up-to-date, summarised evidence-based resources, available from their professional organisation, is preferred. Evidence should reflect the disease burden of the population and involve multifaceted dissemination approaches.
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Affiliation(s)
- Emer O'Brien
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
| | - Aisling Walsh
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, School of Population Health Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Velma Harkins
- Irish College of General Practitioners, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Discipline of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
| | | | - Barbara Clyne
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Department of General Practice, University College Cork, Cork, Ireland
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McCarthy C, Flood M, Clyne B, Smith SM, Boland F, Wallace E, Moriarty F. Association between patient attitudes towards deprescribing and subsequent prescription changes. Basic Clin Pharmacol Toxicol 2023; 133:683-690. [PMID: 36930881 DOI: 10.1111/bcpt.13859] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023]
Abstract
Deprescribing is an essential component of safe prescribing, especially for people with higher levels of polypharmacy. Identifying individuals prepared to consider medicine changes may facilitate deprescribing-orientated reviews. We aimed to explore the relationship between revised patients' attitudes towards deprescribing (rPATD) scores and medication changes in older people prescribed ≥15 medicines. A secondary analysis of rPATD scores and prescription data from a cluster randomised controlled trial of a GP-delivered, deprescribing-orientated medication review was conducted. The association between number of medicines stopped, started and changed and baseline rPATD scores was assessed using Poisson regression, adjusting for patient age, gender, study group allocation, baseline number of medicines and effects of clustering. Participants (n = 404) had a mean age of 76.4 years and were prescribed a mean of 17.1 medicines at baseline. Willingness to stop a medicine was associated with higher rates of both deprescribing (IRR: 1.40; 95% CI: 1.06-1.84) and initiating medicines (IRR: 1.43; 95% CI: 1.09-1.88). Satisfaction with current medicines was associated with a lower rate of deprescribing (IRR: 0.69; 95% CI: 0.57-0.85). The rPATD questionnaire could be used as part of a deprescribing intervention to identify participants who may be prepared to engage in deprescribing, enabling more efficient use of clinician time during complex consultations.
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Affiliation(s)
- Caroline McCarthy
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Susan M Smith
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Fiona Boland
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
- Data Science Centre, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
| | - Frank Moriarty
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
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Mattsson M, Flood M, Wallace E, Boland F, Moriarty F. Eligibility rates and representativeness of the General Medical Services scheme population in Ireland 2016-2021: A methodological report. HRB Open Res 2023; 5:67. [PMID: 37753170 PMCID: PMC10518849 DOI: 10.12688/hrbopenres.13622.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 09/28/2023] Open
Abstract
Background In Ireland, the means tested General Medical Services (GMS) scheme provides access to a range of healthcare services at no or low cost to approximately one third of the population. Individuals eligible for the GMS scheme are often a focus of research, as a population that account for a large proportion of healthcare services use. The aim of this study is to describe the eligibility rates and representativeness of the GMS scheme population over time, with respect to age group, sex, and geographical area in Ireland. Methods Population data was obtained from the Central Statistics Office (CSO), using 2016 Census figures and projected population figures for 2017-2021. GMS eligibility figures for 2016-2021 were obtained from the HSE Primary Care Reimbursement Service (PCRS). GMS eligibility rates and relative rates of eligibility were calculated for 2016-2021 by age group and sex. Additionally, 2016 eligibility rates were calculated by geographical area. Results The crude eligibility rate decreased from 36.4% in 2016 to 31.2% in 2020, with a slight increase to 31.6% in 2021. In the 75+ years age group, 78.2% of the total population were eligible for the GMS scheme in 2021. The age group with the lowest rate of eligible individuals was the 25-34 age group, with 19.5% eligible in 2021. The eligibility rate was higher among females compared to males throughout the study period. The highest eligibility rate was seen in Donegal, with a crude rate of 52.8%. Dublin had the lowest rate, with a crude rate of 29.3%. Conclusions GMS eligibility varies greatly depending on age, sex, and geographical area, and decreased between 2016 and 2021. This study uses the most up-to-date data available to provide age group, sex and area-based figures for GMS eligibility which may inform planning and conduct of research focusing on GMS-eligible individuals.
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Affiliation(s)
| | | | | | - Fiona Boland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Wallace E, Deasy C, Flynn M, McCarthy G, Galvin BTAR. Correction: Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland. BMC Health Serv Res 2023; 23:1075. [PMID: 37814262 PMCID: PMC10563240 DOI: 10.1186/s12913-023-10092-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Affiliation(s)
- Niamh M Cummins
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland.
- Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Louise A Barry
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Carrie Garavan
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Collette Devlin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Fergal Cummins
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Emma Wallace
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Conor Deasy
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Mary Flynn
- Emergency Medicine Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gerard McCarthy
- Emergency Department, Cork University Hospital, Cork, Ireland
- Emergency Medicine Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bdbp Team And Rose Galvin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
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10
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Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Wallace E, Deasy C, Flynn M, McCarthy G, Galvin R. Clinician consensus on "Inappropriate" presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland. BMC Health Serv Res 2023; 23:1003. [PMID: 37723478 PMCID: PMC10506270 DOI: 10.1186/s12913-023-09760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 06/28/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Utilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the "appropriateness" of attendances to the ED in Ireland. METHODS The Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels. RESULTS The National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered "inappropriate" (k = 0.341; p < 0.001). For attendances deemed "appropriate" the admission rate was 47% compared to 0% for "inappropriate" attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites. CONCLUSIONS Multidisciplinary clinicians agree that "inappropriate" use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.
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Affiliation(s)
- Niamh M Cummins
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland.
- Department of Paramedicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Louise A Barry
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Carrie Garavan
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Collette Devlin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Fergal Cummins
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, SLÁINTE Research and Education Alliance in General Practice, Primary Healthcare and Public Health, University of Limerick, Limerick, Ireland
- Emergency Department, ALERT Limerick EM Education Research Training, University Hospital Limerick, Limerick, Ireland
| | - Emma Wallace
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Conor Deasy
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Mary Flynn
- Emergency Medicine Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gerard McCarthy
- Emergency Department, Cork University Hospital, Cork, Ireland
- Emergency Medicine Programme, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rose Galvin
- Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
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Doyle F, Byrne D, Carney RM, Cuijpers P, Dima AL, Freedland K, Guerin S, Hevey D, Kathuria B, Kelly S, McBride S, Wallace E, Boland F. The effects of advanced factor analysis approaches on outcomes in randomised trials for depression: protocol for secondary analysis of individual participant data. BJPsych Open 2023; 9:e157. [PMID: 37565446 PMCID: PMC10594098 DOI: 10.1192/bjo.2023.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 06/28/2023] [Accepted: 07/02/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Modern psychometric methods make it possible to eliminate nonperforming items and reduce measurement error. Application of these methods to existing outcome measures can reduce variability in scores, and may increase treatment effect sizes in depression treatment trials. AIMS We aim to determine whether using confirmatory factor analysis techniques can provide better estimates of the true effects of treatments, by conducting secondary analyses of individual patient data from randomised trials of antidepressant therapies. METHOD We will access individual patient data from antidepressant treatment trials through Clinicalstudydatarequest.com and Vivli.org, specifically targeting studies that used the Hamilton Rating Scale for Depression (HRSD) as the outcome measure. Exploratory and confirmatory factor analytic approaches will be used to determine pre-treatment (baseline) and post-treatment models of depression, in terms of the number of factors and weighted scores of each item. Differences in the derived factor scores between baseline and outcome measurements will yield an effect size for factor-informed depression change. The difference between the factor-informed effect size and each original trial effect size, calculated with total HRSD-17 scores, will be determined, and the differences modelled with meta-analytic approaches. Risk differences for proportions of patients who achieved remission will also be evaluated. Furthermore, measurement invariance methods will be used to assess potential gender differences. CONCLUSIONS Our approach will determine whether adopting advanced psychometric analyses can improve precision and better estimate effect sizes in antidepressant treatment trials. The proposed methods could have implications for future trials and other types of studies that use patient-reported outcome measures.
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Affiliation(s)
- Frank Doyle
- Division of Population Health Sciences, RCSI University of Medicine and Health Sciences, Ireland
| | - David Byrne
- Division of Population Health Sciences, RCSI University of Medicine and Health Sciences, Ireland
| | - Robert M. Carney
- Department of Psychiatry, Washington University School of Medicine, Missouri, USA
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, The Netherlands
| | - Alexandra L. Dima
- Health Psychology and Health Services, Sant Joan de Déu Research Institute, Spain
| | - Kenneth Freedland
- Department of Psychiatry, Washington University School of Medicine, Missouri, USA
| | - Suzanne Guerin
- School of Psychology, University College Dublin, Ireland
| | - David Hevey
- School of Psychology, Trinity College Dublin, Ireland
| | | | - Shane Kelly
- Psychological Society of Ireland, Dublin, Ireland
| | | | - Emma Wallace
- Department of General Practice, University College Cork, Ireland; and Department of General Practice, RCSI University of Medicine and Health Sciences, Ireland
| | - Fiona Boland
- Division of Population Health Sciences, RCSI University of Medicine and Health Sciences, Ireland
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12
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Foley L, Doherty AS, Wallace E, Boland F, Hynes L, Murphy AW, Molloy GJ. Exploring the Multidimensional Relationship Between Medication Beliefs and Adherence to Medications Among Older Adults Living With Multimorbidity Using Polynomial Regression: An Observational Cohort Study. Ann Behav Med 2023; 57:561-570. [PMID: 37000216 PMCID: PMC10312300 DOI: 10.1093/abm/kaad004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND People living with multimorbidity may hold complex beliefs about medicines, potentially influencing adherence. Polynomial regression offers a novel approach to examining the multidimensional relationship between medication beliefs and adherence, overcoming limitations associated with difference scores. PURPOSE To explore the multidimensional relationship between medication beliefs and adherence among people living with multimorbidity. METHODS Secondary analysis was conducted using observational data from a cohort of older adults living with ≥2 chronic conditions, recruited from 15 family practices in Ireland in 2010 (n = 812) and followed up in 2012 (n = 515). Medication beliefs were measured with the Beliefs about Medicines Questionnaire-Specific. Adherence was assessed with the medication possession ratio using prescription data from the national primary care reimbursement service. Polynomial regression was used to explore the best-fitting multidimensional models for the relationship between (i) beliefs and adherence at baseline, and (ii) beliefs at baseline and adherence at follow-up. RESULTS Confirmatory polynomial regression rejected the difference-score model, and exploratory polynomial regression indicated quadratic models for both analyses. Reciprocal effects were present in both analyses (slope [Analysis 1]: β = 0.08, p = .007; slope [Analysis 2]: β = 0.07, p = .044), indicating that adherence was higher when necessity beliefs were high and concern beliefs were low. Nonreciprocal effects were also present in both analyses (slope [Analysis 1]: β = 0.05, p = .006; slope [Analysis 2]: β = 0.04, p = .043), indicating that adherence was higher when both necessity and concern beliefs were high. CONCLUSIONS Among people living with multimorbidity, there is evidence that the relationship between medication beliefs and adherence is multidimensional. Attempts to support adherence should consider the combined role of necessity and concern beliefs.
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Affiliation(s)
- Louise Foley
- School of Psychology, University of Galway, Galway, Ireland
| | - Ann S Doherty
- Department of General Practice, University College Cork, Cork, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
- Data Science Centre, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Lisa Hynes
- Croi Heart and Stroke Charity, Galway, Ireland
| | - Andrew W Murphy
- Discipline of General Practice, University of Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, University of Galway, Galway, Ireland
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13
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Minogue R, Brassil M, Beatty S, Wallace E, Mongan O, Mannion E, Waldron D. Anticipatory Prescribing in End-of-Life: A Completed Audit Loop. Ir Med J 2023; 116:787. [PMID: 37555425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
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14
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Mattsson M, Boland F, Kirke C, Flood M, Wallace E, Walsh ME, Corrigan D, Fahey T, Croker R, Bacon SCJ, Inglesby P, Evans D, Goldacre B, MacKenna B, Moriarty F. The impact of lidocaine plaster prescribing reduction strategies: a comparison of two national health services in Europe. Br J Clin Pharmacol 2023. [PMID: 37164354 DOI: 10.1111/bcp.15779] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION In 2017, two distinct interventions were implemented in Ireland and England to reduce prescribing of lidocaine medicated plasters. In Ireland, restrictions on reimbursement were introduced through implementation of an application system for reimbursement. In England, updated guidance on items which should not be routinely prescribed in primary care, including lidocaine plasters, was published. This study aims to compare how the interventions impacted prescribing of lidocaine plasters in these countries. METHODS We conducted an interrupted time series study using general practice data. For Ireland, monthly dispensing data (2015-2019) from the means-tested General Medical Services (GMS) scheme was used. For England, data covered all patients. Outcomes were the rate of dispensings, quantity and costs of lidocaine plasters, and we modelled level and trend changes from the first full month of the policy/guidance change. RESULTS Ireland had higher rates of lidocaine dispensings compared to England throughout the study period; this was 15.22/1,000 population immediately pre-intervention, and there was equivalent to a 97.2% immediate reduction following the intervention. In England, the immediate pre-intervention dispensing rate was 0.36/1,000, with an immediate reduction of 0.0251/1,000 (a 5.8% decrease), followed by a small but significant decrease in the monthly trend relative to the pre-intervention trend of 0.0057 per month. DISCUSSION Among two different interventions aiming to decrease low-value lidocaine plaster prescribing, there was a substantially larger impact in Ireland of reimbursement restriction compared to issuing guidance in England. However, this is in the context of much higher baseline rates of use in Ireland compared to England.
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Affiliation(s)
- Molly Mattsson
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ciara Kirke
- National Medication Safety Programme, HSE National Quality and Patient Safety Directorate, Dublin, Ireland
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
| | - Mary E Walsh
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland
| | - Derek Corrigan
- FutureNeuro Research Centre (eHealth Group), RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Richard Croker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sebastian C J Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Peter Inglesby
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - David Evans
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
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15
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O'Brien E, Duffy S, Harkins V, Smith SM, O'Herlihy N, Walsh A, Clyne B, Wallace E. A scoping review of evidence-based guidance and guidelines published by general practice professional organizations. Fam Pract 2023:cmad015. [PMID: 36812366 DOI: 10.1093/fampra/cmad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND General practitioners (GPs) need robust, up-to-date evidence to deliver high-quality patient care. There is limited literature regarding the role of international GP professional organizations in developing and publishing clinical guidelines to support GPs clinical decision making. OBJECTIVE To identify evidence-based guidance and clinical guidelines produced by GP professional organizations and summarize their content, structure, and methods of development and dissemination. METHODS Scoping review of GP professional organizations following Joanna Briggs Institute guidance. Four databases were searched and a grey literature search was conducted. Studies were included if they were: (i) evidence-based guidance documents or clinical guidelines produced de novo by a national GP professional organization, (ii) developed to support GPs clinical care, and (iii) published in the last 10 years. GP professional organizations were contacted to provide supplementary information. A narrative synthesis was performed. RESULTS Six GP professional organizations and 60 guidelines were included. The most common de novo guideline topics were mental health, cardiovascular disease, neurology, pregnancy and women's health and preventive care. All guidelines were developed using a standard evidence-synthesis method. All included documents were disseminated through downloadable pdfs and peer review publications. GP professional organizations indicated that they generally collaborate with or endorse guidelines developed by national or international guideline producing bodies. CONCLUSION The findings of this scoping review provide an overview of de novo guideline development by GP professional organizations and can support collaboration between GP organizations worldwide thus reducing duplication of effort, facilitating reproducibility, and identifying areas of standardization. PROTOCOL REGISTRATION Open Science Framework: https://doi.org/10.17605/OSF.IO/JXQ26.
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Affiliation(s)
- Emer O'Brien
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Seamus Duffy
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Velma Harkins
- Irish College of General Practitioners, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin Ireland
| | | | - Aisling Walsh
- Department of Public Health and Epidemiology, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Department of General Practice, University College Cork, Cork, Ireland
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16
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Clyne B, Hynes L, Kirwan C, McGeehan M, Byrne P, Killilea M, Smith SM, Ryan M, Collins C, O'Neill M, Wallace E, Murphy AW, Kelly ME. Perspectives on the production, and use, of rapid evidence in decision making during the COVID-19 pandemic: a qualitative study. BMJ Evid Based Med 2023; 28:48-57. [PMID: 35772940 PMCID: PMC9887371 DOI: 10.1136/bmjebm-2021-111905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To describe perceptions of providing, and using rapid evidence, to support decision making by two national bodies (one public health policy and one front-line clinical practice) during the COVID-19 pandemic. DESIGN Descriptive qualitative study (March-August 2020): 25 semistructured interviews were conducted, transcribed verbatim and thematically analysed. SETTING Data were obtained as part of an evaluation of two Irish national projects; the Irish COVID-19 Evidence for General Practitioners project (General Practice (GP) project) which provided relevant evidence to address clinical questions posed by GPs; and the COVID-19 Evidence Synthesis Team (Health Policy project) which produced rapid evidence products at the request of the National Public Health Emergency Team. PARTICIPANTS Purposive sample of 14 evidence providers (EPs: generated and disseminated rapid evidence) and 11 service ssers (SUs: GPs and policy-makers, who used the evidence). MAIN OUTCOME MEASURES Participant perceptions. RESULTS The Policy Project comprised 27 EPs, producing 30 reports across 1432 person-work-days. The GP project comprised 10 members from 3 organisations, meeting 49 times and posting evidence-based answers to 126 questions. Four unique themes were generated. 'The Work' highlighted that a structured but flexible organisational approach to producing evidence was essential. Ensuring quality of evidence products was challenging, particularly in the context of absent or poor-quality evidence. 'The Use' highlighted that rapid evidence products were considered invaluable to decision making. Trust and credibility of EPs were key, however, communication difficulties were highlighted by SUs (eg, website functionality). 'The Team' emphasised that a highly skilled team, working collaboratively, is essential to meeting the substantial workload demands and tight turnaround time. 'The Future' highlighted that investing in resources, planning and embedding evidence synthesis support, is crucial to national emergency preparedness. CONCLUSIONS Rapid evidence products were considered invaluable to decision making. The credibility of EPs, a close relationship with SUs and having a highly skilled and adaptable team to meet the workload demands were identified as key strengths that optimised the utilisation of rapid evidence. ETHICS APPROVAL Ethical approval was obtained from the National Research Ethics Committee for COVID-19-related Research, Ireland.
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Affiliation(s)
- Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Lisa Hynes
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Colette Kirwan
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Máire McGeehan
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Paula Byrne
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Martha Killilea
- PPI Ignite Network @ NUI Galway, National University of Ireland Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Susan M Smith
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Máirín Ryan
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
- Department of Pharmacology & Therapeutics, St James's Hospital, Trinity College Dublin Faculty of Health Sciences, Dublin, Ireland
| | | | - Michelle O'Neill
- Health Technology Assessment, Health Information and Quality Authority, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Andrew W Murphy
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Maureen E Kelly
- Discipline of General Practice, School of Medicine, National University of Ireland Galway, Galway, Ireland
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17
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McCarthy C, Flood M, Clyne B, Smith SM, Wallace E, Boland F, Moriarty F. Medication changes and potentially inappropriate prescribing in older patients with significant polypharmacy. Int J Clin Pharm 2023; 45:191-200. [PMID: 36385206 DOI: 10.1007/s11096-022-01497-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/01/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Number of medicines and medicines appropriateness are often used as outcome measures to evaluate the effectiveness of deprescribing interventions. AIM The aim of this study was to evaluate changes in prescribing, potentially inappropriate prescriptions (PIP) and prescribing of low-value medicines in older people with multimorbidity and significant polypharmacy. METHOD This study was a retrospective secondary analysis of prescription data from a cluster randomised controlled trial involving 404 participants aged ≥ 65 years and prescribed ≥ 15 repeat medicines from 51 different general practices. For this study, repeat medications at baseline and follow-up (~ 1 year later) were assigned Anatomical Therapeutic Classification (ATC) codes. Outcomes were the most commonly prescribed and potentially inappropriately prescribed drug groups, the most frequently discontinued or initiated drug groups and the number of changes per person between baseline and follow-up. RESULTS There were 7051 medicines prescribed to 404 participants at baseline. There was a median of 17 medicines (IQR 15-19) at baseline and 16 (IQR 14-19) at follow-up. PIP represented 17.1% of prescriptions at baseline and 15.7% (n = 6777) at follow-up. There were reductions in the prescription of most drug groups with the largest reduction in antiplatelet prescriptions. Considering medication discontinuations, initiations and switches, there was a median of five medication changes per person (range 0-30, IQR 3-9) by follow-up. There were 95 low-value prescriptions at baseline reducing to 78 at follow-up. CONCLUSION The number of medication changes per person was not reflected by summarising medication count at two time points, highlighting the complexity of prescribing for patients with polypharmacy. Frequent medication changes has potentially important implications for patients in terms of adherence and medication safety. TRIAL REGISTRY The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).
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Affiliation(s)
- Caroline McCarthy
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,Data Science Centre, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin 2, Ireland
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Cummins N, Barry L, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Cronin S, Wallace E, McCarthy G, Galvin R. Are we there yet?' Distance to definitive care for Irish patients in the Better Data, Better Planning (BDBP) study. Rural Remote Health 2023; 23:8168. [PMID: 36802721 DOI: 10.22605/rrh8168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Residing long distances from definitive care compromises patient safety and, in rural Ireland, travel distance to health care can be substantial, particularly in light of national General Practitioner (GP) shortages and hospital reconfigurations. The aim of this research is to describe the profile of patients attending Irish Emergency Departments (EDs) in terms of distance from GP care and definitive care in the ED. METHOD The 'Better Data, Better Planning' (BDBP) census was a multi-centre, cross-sectional study of n=5 urban and rural EDs in Ireland throughout 2020. At each site, all adults presenting over a 24-h census period were eligible for inclusion. Data were collected on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED, with analysis in SPSS. RESULTS For n=306 participants, median distance to a GP was 3 km (range 1-100 km) and median distance to the ED was 15 km (range 1-160km). Most participants (n=167, 58%) lived within 5 km of their GP and within 10 km of the ED (n=114, 38%). However, 8% of patients lived ≥15 km from their GP and 9% of patients lived ≥50 km from their nearest ED. Patients living >50 km from the ED were more likely to be transported by Ambulance (p<0.05). CONCLUSIONS Proximity to health services, by geographical location, is poorer in rural regions, so it's important that these patients have equity of access to definitive care. Therefore, expansion of alternative care pathways in the community and additional resourcing of the National Ambulance Service with enhanced aeromedical support is essential in the future.
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Affiliation(s)
- Niamh Cummins
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland; and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Louise Barry
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, University of Limerick, Limerick, Ireland; and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Carrie Garavan
- Health Research Institute, University of Limerick, Limerick, Ireland; and School of Nursing & Midwifery, University of Limerick, Limerick, Ireland
| | - Collette Devlin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, University of Limerick, Limerick, Ireland; and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Gillian Corey
- Health Research Institute, University of Limerick, Limerick, Ireland; and ALERT Limerick EM Education Research Training, Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Fergal Cummins
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland; and ALERT Limerick EM Education Research Training, Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Damien Ryan
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland; and ALERT Limerick EM Education Research Training, Emergency Department, University Hospital Limerick, Limerick, Ireland
| | - Sinead Cronin
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emma Wallace
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gerry McCarthy
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Rose Galvin
- School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, University of Limerick, Limerick, Ireland; and Health Research Institute, University of Limerick, Limerick, Ireland
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Gleeson LL, Clyne B, Barlow JW, Ryan B, Murphy P, Wallace E, De Brún A, Mellon L, Hanratty M, Ennis M, Holton A, Pate M, Kirke C, Flood M, Moriarty F. Medication safety incidents associated with the remote delivery of primary care: a rapid review. Int J Pharm Pract 2022; 30:495-506. [PMID: 36595375 DOI: 10.1093/ijpp/riac087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/18/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The COVID-19 pandemic triggered rapid, fundamental changes, notably increased remote delivery of primary care. While the impact of these changes on medication safety is not yet fully understood, research conducted before the pandemic may provide evidence for possible consequences. To examine the published literature on medication safety incidents associated with the remote delivery of primary care, with a focus on telemedicine and electronic prescribing. METHODS A rapid review was conducted according to the Cochrane Rapid Reviews Methods Group guidance. An electronic search was carried out on Embase and Medline (via PubMed) using key search terms 'medication error', 'electronic prescribing', 'telemedicine' and 'primary care'. Identified studies were synthesised narratively; reported medication safety incidents were categorised according to the WHO Conceptual Framework for the International Classification for Patient Safety. KEY FINDINGS Fifteen studies were deemed eligible for inclusion. All 15 studies reported medication incidents associated with electronic prescribing; no studies were identified that reported medication safety incidents associated with telemedicine. The most commonly reported medication safety incidents were 'wrong label/instruction' and 'wrong dose/strength/frequency'. The frequency of medication safety incidents ranged from 0.89 to 81.98 incidents per 100 electronic prescriptions analysed. SUMMARY This review of medication safety incidents associated with the remote delivery of primary care identified common incident types associated with electronic prescriptions. There was a wide variation in reported frequencies of medication safety incidents associated with electronic prescriptions. Further research is required to determine the impact of the COVID-19 pandemic on medication safety in primary care, particularly the increased use of telemedicine.
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Affiliation(s)
- Laura L Gleeson
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - James W Barlow
- Department of Chemistry, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Benedict Ryan
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aoife De Brún
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland
| | - Lisa Mellon
- Division of Population Health Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Marcus Hanratty
- Department of Product Design, National College of Art and Design, Dublin, Ireland
| | - Mark Ennis
- TU Dublin School of Creative Arts, Technological University Dublin City Campus, Dublin, Ireland
| | - Alice Holton
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Muriel Pate
- Quality and Safety Directorate, Health Service Executive, Ireland
| | - Ciara Kirke
- Quality and Safety Directorate, Health Service Executive, Ireland
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Esenwa C, Patel NK, Etienne M, Drugge ED, Wallace E, Ovbiagele B. Trends in diversity, equity and inclusion publications in neurological journals: 2015-2020. J Natl Med Assoc 2022; 114:564-568. [PMID: 36202635 DOI: 10.1016/j.jnma.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Contemporary information on health equity related efforts by scientific neurological journals, as measured by publications related to diversity, equity and inclusion (DEI) and health disparities related to social determinants of health (SDH) are lacking. OBJECTIVE To assess the yearly rates of DEI and SDH related publications in the highest cited general neurology and neurological sub-specialty journals and compare them to the highest cited medical journals over a 6-year period. METHODS We included publications from 15 general neurology and neurological subspecialty journals between January 1st 2015 to December 31st 2020. For comparison we included the 15 most cited medical journals as measured by H-Index. We performed a PubMed search in each of the listed journals using key MeSH terms. Two-proportions Z-test and chi-square trend analyses were used to compare differences between journal types. RESULTS Total yearly proportion of DEI and SDH related publications in neurological journals was 3.9% compared to 6.2% in the highest cited medical journals for years 2015 to 2020 (p=0.001). There was no change in overall trend in publications related to DEI and SDH topics in neurological (ρ = -0.082, p=0.45) or highest cited medical journals between 2015 and 2020 (ρ = -0.065, p=0.54). CONCLUSION Neurological journals had a significantly lower yearly proportion of DEI and SDH related publications compared to top-cited medical journals. Despite heightened awareness of racial/ethnic health disparities and inequities driven by SDH there was no change in related publications in neurological journals between 2015-2020.
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Affiliation(s)
- Charles Esenwa
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, USA.
| | - Nikunj K Patel
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, USA
| | - Mill Etienne
- Department of Neurology, New York Medical College, USA
| | | | - Emma Wallace
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, US
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21
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McRae J, Morgan S, Wallace E, Miles A. Oropharyngeal Dysphagia in Acute Cervical Spinal Cord Injury: A Literature Review. Dysphagia 2022:10.1007/s00455-022-10535-0. [DOI: 10.1007/s00455-022-10535-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
AbstractDysphagia (swallowing impairment) is a frequent complication of cervical spinal cord injury (cSCI). Recently published national guidance in the UK on rehabilitation after traumatic injury confirmed that people with cSCI are at risk for dysphagia and require early evaluation while remaining nil by mouth [National Institute for Health and Care Excellence. Rehabilitation after traumatic injury (NG211), 2022, https://www.nice.org.uk/guidance/ng21]. While the pathogenesis and pathophysiology of dysphagia in cSCI remains unclear, numerous risk factors have been identified in the literature. This review aims to summarize the literature on the risk factors, presentation, assessment, and management of dysphagia in patients with cSCI. A bespoke approach to dysphagia management, that accounts for the multiple system impairment in cSCI, is presented; the overarching aim of which is to support effective management of dysphagia in patients with cSCI to prevent adverse clinical consequences.
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22
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Pertl MM, Perez S, Collier S, Guinan E, Monahan G, Verling K, Wallace E, Walsh A, Doyle F. Effective maNagement of depression among patients witH cANCEr (ENHANCE): a protocol for a hybrid systematic review and network meta-analysis of randomised controlled trials of interventions for depressive symptoms. Syst Rev 2022; 11:239. [PMID: 36371235 PMCID: PMC9655794 DOI: 10.1186/s13643-022-02107-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 10/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Depression is common among patients with cancer and is associated with lower treatment participation, lower satisfaction with care, poorer quality of life, greater symptom burden and higher healthcare costs. Various types of interventions (e.g. pharmacological, psychotherapy) are used for the treatment of depression. However, evidence for these among patients with cancer is limited. Furthermore, the relative effectiveness and acceptability of different approaches are unknown because a direct comparison between all available treatments has not been carried out. We will address this by conducting a network meta-analysis (NMA) of interventions for depression among people with cancer using a hybrid overview of reviews and systematic review methodology. METHODS We will search for and extract data from systematic reviews of randomised controlled trials (RCTs) of depression interventions for patients with cancer from inception, before performing a supplemental search for more recent RCTs. We will include RCTs comparing pharmacological, psychotherapy, exercise, combination therapy, collaborative care or complementary and alternative medicine interventions with pill placebo, no treatment, waitlist, treatment as usual or minimal treatment control groups, or directly in head-to-head trials, among adults who currently have cancer or have a history of any cancer and elevated depressive symptoms (scores above a cut-off on validated scales or meeting diagnostic criteria). Our primary outcomes will be change in depressive symptoms (standardised mean difference) and intervention acceptability (% who withdrew). Our secondary outcomes will be 6-month change in depressive symptoms, health-related quality of life, adverse events and mortality. We will independently screen for eligibility, extract data and assess risk of bias using the RoB 2 tool. We will use frequentist random-effects multivariate NMA in Stata, rankograms and surface under the cumulative ranking curves to synthesise evidence and obtain a ranking of intervention groups. We will explore heterogeneity and inconsistency using local and global measures and evaluate the credibility of results using the Confidence in NEtwork Meta-Analysis (CINeMA) framework. DISCUSSION Our findings will provide the best available evidence for managing depression among patients with cancer. Such information will help to inform clinical guidelines, evidence-based treatment decisions and future research by identifying gaps in the current literature. SYSTEMATIC REVIEW REGISTRATION Submitted to PROSPERO (record number: 290145), awaiting registration.
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Affiliation(s)
- Maria M Pertl
- Department of Health Psychology, School of Population Health, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephen's Green, Dublin, 2, Ireland.
| | - Sergio Perez
- School of Social Work and Social Policy, Trinity College Dublin (TCD), Dublin, 2, Ireland
| | - Sonya Collier
- Psycho-Oncology Unit, St. James's Hospital Dublin, Dublin, 8, Ireland
| | - Emer Guinan
- Trinity Exercise Oncology Research Group, Discipline of Physiotherapy, Faculty of Health Sciences, TCD, Dublin, 2, Ireland
| | | | | | - Emma Wallace
- Department of General Practice, , University College Cork, Cork, Ireland
| | - Aisling Walsh
- Department of Public Health and Epidemiology, School of Population Health, RCSI, 123 St. Stephen's Green, Dublin, 2, Ireland
| | - Frank Doyle
- Department of Health Psychology, School of Population Health, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephen's Green, Dublin, 2, Ireland
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23
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Murphy AW, Moran D, Smith SM, Wallace E, Glynn LG, Hanley K, Kelly ME. Supporting Medical Students Towards Future Careers in General Practice: A Quantitative Study of Irish Medical Schools. Ir Med J 2022; 115:10. [PMID: 36917466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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24
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Turk A, Wong G, Mahtani KR, Maden M, Hill R, Ranson E, Wallace E, Krska J, Mangin D, Byng R, Lasserson D, Reeve J. Correction: Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review. BMC Med 2022; 20:401. [PMID: 36266686 PMCID: PMC9585860 DOI: 10.1186/s12916-022-02611-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Amadea Turk
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Michelle Maden
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ruaraidh Hill
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ed Ranson
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
| | - Emma Wallace
- Department of General Practice RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, Kent, ME4 4TB, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, L8P 1H6, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, PL4 8AA, UK
| | - Daniel Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK.
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25
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McCarthy C, Pericin I, Smith SM, Kiely B, Moriarty F, Wallace E, Clyne B. Patient and general practitioner experiences of implementing a medication review intervention in older people with multimorbidity: Process evaluation of the SPPiRE trial. Health Expect 2022; 25:3225-3237. [PMID: 36245339 DOI: 10.1111/hex.13630] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The SPPiRE cluster randomized controlled trial found that a general practitioner (GP)-delivered medication review that incorporated screening for potentially inappropriate prescriptions (PIP), a brown bag review and a patient priority assessment, resulted in a significant but small reduction in the number of medicines and no significant reduction in PIP. This process evaluation aims to explore the experiences of GPs and patients and the potential for system-wide implementation. METHODS The trial included 51 general practices and 404 participants with multimorbidity aged ≥65 years, prescribed ≥15 medicines. The process evaluation used mixed methods and ran parallel to the trial. Quantitative data was collected from the SPPiRE intervention website and analysed descriptively. Qualitative data on medication changes were collected from intervention GPs (18/26) and a purposive sample of intervention patients (27/208) via semi-structured telephone interviews. All interviews were transcribed verbatim and analysed using a thematic analysis. Qualitative and quantitative data were integrated using a triangulation protocol. RESULTS The analysis generated two themes, intervention implementation and mechanisms of action, and both were underpinned by the theme of context. Intervention delivery varied among practices and 45 patients (28%) had no review, primarily due to insufficient GP time. 80% of reviewed patients had ≥1 PIP identified, 59% had ≥1 problem identified during the brown bag review and 79% had ≥1 priority recorded. The brown bag review resulted in the most deprescription of medications. GPs and patients responded positively to the intervention but most GPs did not engage with the patient priority-setting process. GPs identified a lack of integration into practice software and resources as barriers to future implementation. CONCLUSION The SPPiRE intervention had a small effect in reducing the number of medicines and this was primarily mediated through the brown bag review. The context of resource shortages and deep-seated views around medical decision-making influenced intervention implementation. PATIENT OR PUBLIC CONTRIBUTION Qualitative data on the implementation of the medication review and their wider views on their medicines was collected from older people with multimorbidity through semi-structured telephone interviews. CLINICAL TRIAL REGISTRATION The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).
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Affiliation(s)
- Caroline McCarthy
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ivana Pericin
- School of Social Work and Social Policy, Trinity College Dublin, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland.,Department of Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
| | - Bridget Kiely
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Barbara Clyne
- Department of General Practice, HRB Centre for Primary Care Research, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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26
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Doherty AS, Shahid F, Moriarty F, Boland F, Clyne B, Dreischulte T, Fahey T, Kennelly SP, Wallace E. Prescribing cascades in community-dwelling adults: A systematic review. Pharmacol Res Perspect 2022; 10:e01008. [PMID: 36123967 PMCID: PMC9485823 DOI: 10.1002/prp2.1008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/15/2022] Open
Abstract
The misattribution of an adverse drug reaction (ADR) as a symptom or illness can lead to the prescribing of additional medication, referred to as a prescribing cascade. The aim of this systematic review is to identify published prescribing cascades in community-dwelling adults. A systematic review was reported in line with the PRISMA guidelines and pre-registered with PROSPERO. Electronic databases (Medline [Ovid], EMBASE, PsycINFO, CINAHL, Cochrane Library) and grey literature sources were searched. Inclusion criteria: community-dwelling adults; risk-prescription medication; outcomes-initiation of new medicine to "treat" or reduce ADR risk; study type-cohort, cross-sectional, case-control, and case-series studies. Title/abstract screening, full-text screening, data extraction, and methodological quality assessment were conducted independently in duplicate. A narrative synthesis was conducted. A total of 101 studies (reported in 103 publications) were included. Study sample sizes ranged from 126 to 11 593 989 participants and 15 studies examined older adults specifically (≥60 years). Seventy-eight of 101 studies reported a potential prescribing cascade including calcium channel blockers to loop diuretic (n = 5), amiodarone to levothyroxine (n = 5), inhaled corticosteroid to topical antifungal (n = 4), antipsychotic to anti-Parkinson drug (n = 4), and acetylcholinesterase inhibitor to urinary incontinence drugs (n = 4). Identified prescribing cascades occurred within three months to one year following initial medication. Methodological quality varied across included studies. Prescribing cascades occur for a broad range of medications. ADRs should be included in the differential diagnosis for patients presenting with new symptoms, particularly older adults and those who started a new medication in the preceding 12 months.
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Affiliation(s)
- Ann S. Doherty
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Faiza Shahid
- Institute of General Practice and Family MedicineUniversity Hospital of Ludwig‐Maximilians‐University MunichMunichGermany
| | - Frank Moriarty
- School of Pharmacy and Biomolecular SciencesRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Fiona Boland
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
- Data Science CentreRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Barbara Clyne
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Tobias Dreischulte
- Institute of General Practice and Family MedicineUniversity Hospital of Ludwig‐Maximilians‐University MunichMunichGermany
| | - Tom Fahey
- Department of General PracticeRCSI University of Medicine and Health SciencesDublin 2Ireland
| | - Seán P. Kennelly
- Department of Medical GerontologyTrinity College DublinDublin 2Ireland
- Department of Age‐related HealthcareTallaght University HospitalDublin 24Ireland
| | - Emma Wallace
- Department of General PracticeUniversity College CorkCorkIreland
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27
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Turk A, Wong G, Mahtani KR, Maden M, Hill R, Ranson E, Wallace E, Krska J, Mangin D, Byng R, Lasserson D, Reeve J. Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review. BMC Med 2022; 20:297. [PMID: 36042454 PMCID: PMC9429627 DOI: 10.1186/s12916-022-02475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy. METHODS The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses. RESULTS We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework. CONCLUSION Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.
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Affiliation(s)
- Amadea Turk
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
| | - Michelle Maden
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ruaraidh Hill
- Liverpool Reviews & Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, L69 3BX, UK
| | - Ed Ranson
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK
| | - Emma Wallace
- Department of General Practice RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham Maritime, Kent, ME4 4TB, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, L8P 1H6, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, PL4 8AA, UK
| | - Daniel Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joanne Reeve
- Academy of Primary Care, Hull York Medical School, Allam Medical Building, University of Hull, Hull, HU6 7RX, UK.
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Zagona-Prizio C, Sivesind T, Szeto M, Wallace E, Sillau S, Liu Y, Leehey M, Dunnick C, Dellavalle R. LB948 Oral cannabidiol treatment of seborrheic dermatitis in patients with Parkinson’s disease. J Invest Dermatol 2022. [DOI: 10.1016/j.jid.2022.05.967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Waldron C, Hughes J, Wallace E, Cahir C, Bennett K. Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13580.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required. A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version. The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods: Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results: Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions: To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.
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O'Dwyer P, Guzman V, Wallace E, Doyle F. A scoping review protocol of non-verbal communication utilised in peri-interventive dental and medical procedures. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13373.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: Dental operative procedures, by their interventive nature, impede the opportunity for peri-intervention verbal communication between patients and clinicians. This can impair trust, consent, and shared decision making with the potential of adversely affecting patient dignity, and potentially resulting in suboptimal clinical outcomes. This scoping review aims to interrogate the literature concerning non-verbal communication methods used in dental and medical practices during peri-interventive procedures, in aiding communication between clinician and patient. We will also ascertain how these align with the Limited Capacity Model of Motivated Mediated Message Processing (LC4MP) communication theory. Methods: The framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews, will be used to guide this scoping review and reporting methodology. Selected electronic databases (Medline, Embase, Cochrane Library and Scopus), PsychInfo, CINAHL and grey literature sources will be searched. Inclusion criteria are: articles written in the English language, publications between 2000 and 2020, peer-reviewed empirical studies, with either qualitative or quantitative data, mixed methods, reviews, book chapters and grey literature with a principal focus on non-verbal communication in the healthcare setting. A narrative synthesis will be conducted, with results reported according to elements of LCM4P theory: cognitive load, motivated messaging, message processing and memory. Conclusion: This scoping review will contribute to our methodological and theoretical understanding of the use of non-verbal communication strategies in clinical settings.
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Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, Lasserson D, Krska J, Mangin D, Byng R, Wallace E, Ranson E. Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis. Health Technol Assess 2022; 26:1-148. [PMID: 35894932 DOI: 10.3310/aafo2475] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy. OBJECTIVES We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice. DATA SOURCES Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches). REVIEW METHODS The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus. RESULTS Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust. LIMITATIONS Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available. CONCLUSIONS Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models. FUTURE WORK The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice. STUDY REGISTRATION This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne Reeve
- Academy of Primary Care, Hull York Medical School, University of Hull, Hull, UK
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Amadea Turk
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dan Lasserson
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Janet Krska
- Medway School of Pharmacy, Universities of Greenwich and Kent, Chatham, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Gleeson LL, Ludlow A, Wallace E, Argent R, Collins C, Clyne B, Mellon L, Barlow JW, Ryan B, De Brún A, Holton A, Pate M, Kirke C, Flood M, Moriarty F. Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: A survey study. Exploratory Research in Clinical and Social Pharmacy 2022; 6:100143. [PMID: 35702683 PMCID: PMC9182324 DOI: 10.1016/j.rcsop.2022.100143] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction The COVID-19 pandemic has had a profound impact on the delivery of primary care around the world. In Ireland, the use of technologies such as virtual consultations and the electronic transfer of prescriptions became widespread in order to deliver care to patients while minimising infection risk. The impact of these changes on medication safety is not yet known. Objectives The aims of this survey study were to investigate 1) the changes that have occurred in Irish primary care since the start of the COVID-19 pandemic and 2) the impact of these changes on medication safety. Methods Anonymous, online surveys were distributed to general practitioners (GPs) and pharmacists from August–September 2021. Surveys contained quantitative (multiple-choice, Likert scale) and qualitative (free-text) questions concerning workflow changes, medication safety incidents and near misses, and GP/pharmacist perspectives on medication safety and COVID-19. Reported medication safety incidents and near misses were categorised according to the WHO Conceptual Framework for the International Classification for Patient Safety. Results In total, there were 251 responses to the survey, comprising of 211 pharmacists and 40 GPs. The most significant workflow changes during the pandemic were the widespread use of a secure clinical email service (Healthmail) that facilitates electronic prescription transfer and communication (75.3% of respondents) and the increased use of telephone consultations (49%). Overall, Healthmail was widely perceived to have had a positive impact on medication safety. Most GPs did not perceive a change in the frequency of medication safety incidents during the pandemic, while most pharmacists reported a slight increase in incidents. Survey participants highlighted pressure, patient expectations, and patient monitoring as significant challenges encountered during the pandemic. Conclusions During the pandemic, a number of significant changes occurred in primary care in Ireland, particularly involving communication of healthcare information, with varying impacts on workflow and medication safety. Future research should focus on the optimisation of electronic prescribing and telemedicine services in Ireland, patient perspectives on the changes in primary care, and interventions to improve medication safety in primary care.
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Affiliation(s)
- Laura L. Gleeson
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aoife Ludlow
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Rob Argent
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Claire Collins
- Research Unit, Irish College of General Practitioners, Dublin, Ireland
| | - Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Lisa Mellon
- Division of Population Health Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - James W. Barlow
- Department of Chemistry, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Benedict Ryan
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Aoife De Brún
- UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland
| | - Alice Holton
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Muriel Pate
- National Medication Safety Programme, National Quality and Patient Safety Directorate, Health Service Executive, Ireland
| | - Ciara Kirke
- National Medication Safety Programme, National Quality and Patient Safety Directorate, Health Service Executive, Ireland
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Corresponding author.
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Brazil K, Cardwell C, Carter G, Clarke M, Corry DAS, Fahey T, Gillespie P, Hobbins A, McGlade K, O'Halloran P, O'Neill N, Wallace E, Doyle F. Anticipatory care planning for community-dwelling older adults at risk of functional decline: a feasibility cluster randomized controlled trial. BMC Geriatr 2022; 22:452. [PMID: 35610581 PMCID: PMC9131621 DOI: 10.1186/s12877-022-03128-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 05/11/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To determine the feasibility, implementation and outcomes of an Anticipatory Care Planning (ACP) intervention in primary care to assist older adults at risk of functional decline by developing a personalized support plan. Design Feasibility cluster randomized control trial. Setting and participants Eight primary care practices (four in Northern Ireland, United Kingdom and four in the Republic of Ireland) were randomly assigned to either intervention or control arm. Eligible patients were those identified in each practice as 70 years of age or older and assessed as at risk of functional decline. Study participants (intervention n = 34, control n = 31) and research staff were not blinded to group assignment. Anticipatory care intervention The intervention delivered by a registered nurse including: a) a home-based patient assessment; b) care planning on the basis of a holistic patient assessment, and c) documentation of a support plan. Outcome measures A conceptual framework (RE-AIM) guided the assessment on the potential impact of the ACP intervention on patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and reduction of potentially inappropriate prescribing. Data were collected at baseline and at 10 weeks and six months following delivery of the intervention. Results All pre-specified feasibility indicators were met. Patients were unanimous in the acceptance of the ACP intervention. Health care providers viewed the ACP intervention as feasible to implement in routine clinical practice with attending community supports. While there were no significant differences on the primary outcomes (EQ-5D-5L: -0.07 (-0.17, 0.04) p = .180; CES-D: 1.2 (-2.5, 4.8) p = .468) and most secondary measures, ancillary analysis on social support showed responsiveness to the intervention. Incremental cost analysis revealed a mean reduction in costs of €320 per patient (95% CI -31 to 25; p = 0.82) for intervention relative to the control. Conclusions We successfully tested the ACP intervention in primary care settings and have shown that it is feasible to implement. The ACP intervention deserves further testing in a definitive trial to determine whether its implementation would lead to better outcomes or reduced costs. Trial registration Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03128-x.
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Affiliation(s)
- Kevin Brazil
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Christopher Cardwell
- Centre for Public Health, ICSB, Royal Victoria Hospital, Queen's University, Belfast, UK
| | - Gillian Carter
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Mike Clarke
- Centre for Public Health, ICSB, Royal Victoria Hospital, Queen's University, Belfast, UK
| | - Dagmar Anna S Corry
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Patrick Gillespie
- Health Economics and Policy Analysis Centre, Institute for Lifecourse and Society, National University of Ireland, Galway (NUI Galway), Republic of Ireland
| | - Anna Hobbins
- Health Economics and Policy Analysis Centre, Institute for Lifecourse and Society, National University of Ireland, Galway (NUI Galway), Republic of Ireland
| | - Kieran McGlade
- School of Medicine, Dentistry, and Biomedical Sciences, Dunluce Health Centre, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Nina O'Neill
- School of Social Sciences, Education and Social Work, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland.,Department of Health Psychology, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Frank Doyle
- Department of Health Psychology, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
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Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, Ryan D, Cronin S, Wallace E, McCarthy G, Galvin R. The “better data, better planning” census: a cross-sectional, multi-centre study investigating the factors influencing patient attendance at the emergency department in Ireland. BMC Health Serv Res 2022; 22:471. [PMID: 35397588 PMCID: PMC8994521 DOI: 10.1186/s12913-022-07841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Internationally Emergency Department (ED) crowding is a significant health services delivery issue posing a major risk to population health. ED crowding affects both the quality and access of health services and is associated with poorer patient outcomes and increased mortality rates. In Ireland the practising of “Corridor Medicine” and “Trolley Crises” have become prevalent. The objectives of this study are to describe the demographic and clinical profile of patients attending regional EDs and to investigate the factors influencing ED utilisation in Ireland. Methods This was a multi-centre, cross-sectional study and recruitment occurred at a selection of urban and rural EDs (n = 5) in Ireland throughout 2020. At each site all adults presenting over a 24 h census period were eligible for inclusion. Clinical data were collected via electronic records and a questionnaire provided information on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED. Results Demographics differed significantly between ED sites in terms of age (p ≤ 0.05), socioeconomic status (p ≤ 0.001), and proximity of health services (p ≤ 0.001). Prior to ED attendance 64% of participants accessed community health services. Most participants (70%) believed the ED was the “best place” for emergency care or attended due to lack of awareness of other services (30%). Musculoskeletal injuries were the most common reason for presentation to the ED in this study (24%) and almost a third of patients (31%) reported presenting to the ED for an x-ray or scan. Conclusions This study has identified regional and socioeconomic differences in the drivers of ED presentations and factors influencing ED attendance in Ireland from the patient perspective. Improved awareness of, and provision of alternative care pathways could potentially decrease ED attendances, which would be important in the context of reducing ED crowding during the COVID-19 pandemic. New strategies for integration of acute care in the community must acknowledge and plan for these issues as a universal approach is unlikely to be implemented successfully due to regional factors. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07841-6.
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Mattsson M, Boland F, Kirke C, Flood M, Quinn E, Walsh M, Corrigan D, MacKenna B, Fahey T, Wallace E, Moriarty F. Evaluation of policies and practices to support safe and appropriate analgesic and sedative prescribing: The CDRx (controlled drug prescribing) protocol. Res Social Adm Pharm 2022; 18:3588-3595. [DOI: 10.1016/j.sapharm.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/16/2022]
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O'Brien E, Clyne B, Smith SM, O'Herlihy N, Harkins V, Wallace E. A scoping review protocol of evidence-based guidance and guidelines published by general practitioner professional organisations. HRB Open Res 2022; 4:53. [PMID: 35233505 PMCID: PMC8866908 DOI: 10.12688/hrbopenres.13268.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/09/2023] Open
Abstract
Introduction: General practitioners (GPs) strive to use a patient centered approach to achieve shared decision making by integrating clinical evidence, clinical judgement, and patient priorities. In order to achieve this standard of care, GPs require relevant, up to date and high quality evidence. Currently there is a gap in the literature regarding the role of GP professional organisations internationally in producing and publishing evidence based guidance and clinical guidelines for GPs. This protocol outlines a scoping review to identify what evidence-based guidance is produced by general practitioner professional organisations internationally in terms of topic content, the structure and methods used to develop guidance and ways of disseminating this guidance, to support general practice clinical decision making. Methods: This scoping review will be conducted using the framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR), will be used to guide the reporting. Two researchers will search electronic databases (Medline, Embase, Cochrane Library and Scopus), grey literature sources and contact international GP professional organisations directly to identify appropriate studies for inclusion. Key information will be categorised and classified to generate a summary of the methods used internationally to develop and implement evidence-based guides for general practitioners and a narrative synthesis will be conducted. Conclusions: This scoping review will examine current practice internationally regarding the role of General Practice professional organisations in producing and publishing clinical guidelines and evidence based guidance to support general practitioner's clinical decision making to benefit patient care.
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Affiliation(s)
- Emer O'Brien
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
| | - Barbara Clyne
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
| | - Susan M. Smith
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
| | - Noirin O'Herlihy
- Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2, D02XR68, Ireland
| | - Velma Harkins
- Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2, D02XR68, Ireland
| | - Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
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O'Brien E, Clyne B, Smith SM, O'Herlihy N, Harkins V, Wallace E. A scoping review protocol of evidence-based guidance and guidelines published by general practitioner professional organisations. HRB Open Res 2022; 4:53. [PMID: 35233505 PMCID: PMC8866908 DOI: 10.12688/hrbopenres.13268.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: General practitioners (GPs) strive to use a patient centered approach to achieve shared decision making by integrating clinical evidence, clinical judgement, and patient priorities. In order to achieve this standard of care, GPs require relevant, up to date and high quality evidence. Currently there is a gap in the literature regarding the role of GP professional organisations internationally in producing and publishing evidence based guidance and clinical guidelines for GPs. This protocol outlines a scoping review to identify what evidence-based guidance is produced by general practitioner professional organisations internationally in terms of topic content, the structure and methods used to develop guidance and ways of disseminating this guidance, to support general practice clinical decision making. Methods: This scoping review will be conducted using the framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR), will be used to guide the reporting. Two researchers will search electronic databases (Medline, Embase, Cochrane Library and Scopus), grey literature sources and contact international GP professional organisations directly to identify appropriate studies for inclusion. Key information will be categorised and classified to generate a summary of the methods used internationally to develop and implement evidence-based guides for general practitioners and a narrative synthesis will be conducted. Conclusions: This scoping review will examine current practice internationally regarding the role of General Practice professional organisations in producing and publishing clinical guidelines and evidence based guidance to support general practitioner’s clinical decision making to benefit patient care.
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Affiliation(s)
- Emer O'Brien
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
| | - Barbara Clyne
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
| | - Susan M. Smith
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
| | - Noirin O'Herlihy
- Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2, D02XR68, Ireland
| | - Velma Harkins
- Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2, D02XR68, Ireland
| | - Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, D02H903, Ireland
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Corry DAS, Carter G, Doyle F, McGlade K, O'Halloran P, Wallace E, Brazil K. Lessons from a feasibility study testing an anticipatory care planning intervention for older adults at risk of functional decline: feedback from implementing stakeholders. Pilot Feasibility Stud 2022; 8:10. [PMID: 35045877 PMCID: PMC8767659 DOI: 10.1186/s40814-022-00973-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/11/2022] [Indexed: 11/14/2022] Open
Abstract
Background Anticipatory care is becoming increasingly important in effectively managing complex multimorbidity in aging populations, preventing further functional decline, and avoiding hospital admissions. This study aimed to elicit the feedback of participating general practitioners, practice managers, nurses and an adjunct pharmacist on the implementation strengths and limitations of a nurse-led, person-centered anticipatory care planning (ACP) intervention for older people at risk of functional decline in a primary care setting. The findings have implications for a full trial and intervention design. Methods As part of a feasibility cluster randomized controlled trial (cRCT) testing the ACP intervention, we sought feedback from implementing stakeholders: general practitioners (N = 3), practice staff (N = 3), research nurses (N = 5), and adjunct pharmacist (N = 1) in both the Republic of Ireland (ROI) and Northern Ireland (NI), UK. Following written, informed consent, they were interviewed to investigate their experience of participating in the implementation of the ACP intervention as part of the feasibility trial, and elicit any recommendations for a full trial. Using the Consolidated Framework for Implementation Research, thematic analysis was employed to analyze data. The intervention consisted of home visits by specially trained nurses who assessed participants’ health, discussed with them their health goals and plans, and devised an anticipatory care plan following consultation with participants’ General Practitioners and the adjunct clinical pharmacist. Results Participating stakeholders indicated that the strengths of the implementation process included the training provided to the nurses, constructive collaboration of the research team, and structure of implementation process. Perceived limitations included the selection process and screening tool, communication between the research team and the nurses, the assessment questionnaire, and the final document left with the patient, as well as lack of access to medical records for the adjunct pharmacist. Recommendations include better communication and team-wide consensus on alterations to procedure and documents, and standardized protocols for patient selection, data collection, and reporting for research nurses. Conclusions The findings have identified strengths of the implementation process on which to build, and recognized limitations which can now be addressed to ensure improved efficiency and effectiveness in future trials. Trial registration Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-00973-w.
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Affiliation(s)
- Dagmar Anna S Corry
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK. .,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Gillian Carter
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK.,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Frank Doyle
- Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Kieran McGlade
- School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Dunluce Health Centre, Belfast, Northern Ireland, UK
| | - Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Emma Wallace
- Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland.,Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Kevin Brazil
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK. .,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK.
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Smith SM, Wallace E, Clyne B, Boland F, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community setting: a systematic review. Syst Rev 2021; 10:271. [PMID: 34666828 PMCID: PMC8527775 DOI: 10.1186/s13643-021-01817-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/16/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Multimorbidity, defined as the co-existence of two or more chronic conditions, presents significant challenges to patients, healthcare providers and health systems. Despite this, there is ongoing uncertainty about the most effective ways to manage patients with multimorbidity. This review updated and narrowed the focus of a previous Cochrane review and aimed to determine the effectiveness of interventions designed to improve outcomes in people with multimorbidity in primary care and community settings, compared to usual care. METHODS We searched eight databases and two trials registers up to 9 September 2019. Two review authors independently screened potentially eligible titles and selected studies, extracted data, evaluated study quality and judged the certainty of the evidence (GRADE). Interventions were grouped by their predominant focus into care-coordination/self-management support, self-management support and medicines management. Main outcomes were health-related quality of life (HRQoL) and mental health. Meta-analyses were conducted, where possible, but the synthesis was predominantly narrative. RESULTS We included 16 RCTs with 4753 participants, the majority being older adults with at least three conditions. There were eight care-coordination/self-management support studies, four self-management support studies and four medicines management studies. There was little or no evidence of an effect on primary outcomes of HRQoL (MD 0.03, 95% CI -0.01 to 0.07, I2 = 39%) and mental health or on secondary outcomes with a small number of studies reporting that care coordination may improve patient experience of care and self-management support may improve patient health behaviours. Overall, the certainty of the evidence was graded as low due to significant variation in study participants and interventions. CONCLUSIONS There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity, despite the growing number of RCTs conducted in this area. Our findings suggest that future research should consider patient experience of care, optimising medicines management and targeted patient health behaviours such as exercise.
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Affiliation(s)
- Susan M. Smith
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Emma Wallace
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Barbara Clyne
- Department of General Practice and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Fiona Boland
- Data Science Centre and HRB Centre for Primary Care Research, Royal College of Surgeons, 123 St Stephens Green, Dublin 2, Ireland
| | - Martin Fortin
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Quebec, Canada
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Doherty A, Moriarty F, Boland F, Clyne B, Fahey T, Kennelly S, Wallace E. Prescribing cascades in community-dwelling adults: protocol for a systematic review. HRB Open Res 2021; 4:72. [PMID: 34738069 PMCID: PMC8529400 DOI: 10.12688/hrbopenres.13345.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 01/04/2023] Open
Abstract
Introduction: Internationally, health systems face the challenge of managing a growing ageing population living with multimorbidity and polypharmacy. Potentially inappropriate prescribing is common among patients with polypharmacy, increasing the risk for adverse drug reactions (ADRs). Several prescribing indicator sets exist to improve prescribing and reduce potentially inappropriate prescribing, but do not address prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat an ADR to another prescribed medication, whether intentionally or unintentionally, and constitute an important area to consider when characterising problematic polypharmacy. This is a protocol for a systematic review examining prescribing cascades in community-dwelling adults. Methods: The review will be reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of Medline (Ovid), EMBASE, PsycINFO, CINAHL and the Cochrane Library will be conducted from inception to March 2021, using a predetermined strategy. Grey literature will be searched using Open Grey, MedNar, Dart Europe, and the Turning Research Into Practice (TRIP) databases. No restrictions will be placed on language or publication year. Inclusion criteria are: population - community-dwelling adults (≥18 years); risk - prescription medication with the potential to cause side effects; outcomes - initiation of a new medicine to 'treat' or reduce the risk of experiencing an ADR. Prospective and retrospective cohort studies, case control and case series studies will be included. Two reviewers will independently screen titles and abstracts; studies meeting inclusion criteria will undergo independent full-text screening by two reviewers. A narrative synthesis will be conducted. Study quality will be independently assessed using the relevant Joanna Briggs Institute Critical Appraisal Checklist. Discussion: This systematic review will identify examples of prescribing cascades for community-dwelling adults and contribute to developing an evidence base regarding such cascades. Registration: PROSPERO [ CRD42021243163, 31/03/2021].
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Affiliation(s)
- Ann Doherty
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Fiona Boland
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
- Data Science Centre, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Seán Kennelly
- Department of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
- Department of Age-related Healthcare, Tallaght University Hospital, Dublin 24, Ireland
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
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Quinn D, Byrne D, Fahey T, Kenny RA, McGarrigle C, Wallace E, Boland F. Overuse and underuse of cardiovascular diagnostic and therapeutic procedures for community-dwelling adults: a protocol for a systematic review. HRB Open Res 2021; 4:99. [PMID: 35402780 PMCID: PMC8976182 DOI: 10.12688/hrbopenres.13330.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Potentially inappropriate care can result from overuse or underuse of treatments, tests, or procedures. Overuse is defined as the use of health services with no clear benefit to the recipient or where harms outweigh benefits and/or costs of care. Underuse is defined as failure to deliver an effective and cost-effective healthcare intervention. Cardiovascular procedures such as coronary artery bypass grafting, carotid endarterectomy, coronary angiography, and coronary angioplasty (with/without stenting) are potentially both underused and overused. This systematic review aims to identify rates of potential overuse and underuse of these cardiovascular procedures and explore any associated patient or healthcare system factors. Methods: A systematic review and meta-analysis will be conducted in accordance with the PRISMA guidelines. A systematic search of MEDLINE (via Ovid), Embase, Cumulative Index to Nursing and Allied Health Literature and the Cochrane library will be conducted using a predefined search strategy. Eligible studies for inclusion will examine rates of overuse and underuse of cardiovascular procedures, measured against national/international guidelines, for adults aged ≥18 years. Primary observational studies including cross-sectional and cohort studies will be included. Titles, abstracts, and full texts will be screened for inclusion by two reviewers. Data will be extracted using a standardised form. Risk of bias for all included studies will be assessed using a modified version of the Hoy risk of bias tool. Where adequate data exists, and if statistically appropriate, meta-analyses will be conducted. If statistical pooling of the data is not possible, the findings will be narratively summarised focusing on the review’s objectives. Conclusion: This systematic review will examine overuse and underuse of cardiovascular procedures for adults. The results will help inform policy makers, researchers, patients, and clinicians in the appropriate use of these procedures, in line with international guidelines. Registration: This protocol has been submitted for registration on PROSPERO (CRD42021239041).
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Affiliation(s)
- Dominic Quinn
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - David Byrne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Christine McGarrigle
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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Corry DAS, Carter G, Doyle F, Fahey T, Gillespie P, McGlade K, O'Halloran P, O'Neill N, Wallace E, Brazil K. Successful implementation of a trans-jurisdictional, primary care, anticipatory care planning intervention for older adults at risk of functional decline: interviews with key health professionals. BMC Health Serv Res 2021; 21:871. [PMID: 34433441 PMCID: PMC8387014 DOI: 10.1186/s12913-021-06896-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/12/2021] [Indexed: 02/07/2023] Open
Abstract
Background Aging populations present a challenge to health systems internationally, due to the increasing complexity of care for older adults living with functional decline. This study aimed to elicit expert views of key health professionals on effective and sustainable implementation of a nurse-led, person-centred anticipatory care planning (ACP) intervention for older adults at risk of functional decline in a primary care setting. Methods We examined the feasibility of an ACP intervention in a trans-jurisdictional feasibility cluster randomized controlled trial consisting of home visits by research nurses who assessed participants’ health, discussed their health goals and devised an anticipatory care plan following consultation with participants’ GPs and adjunct clinical pharmacist. As part of the project, we elicited the views and recommendations of experienced key health professionals working with the target population who were recruited using a ‘snowballing technique’ in cooperation with older people health networks in the Republic of Ireland (ROI) and Northern Ireland (NI), United Kingdom [n = 16: 7 ROI, 9 NI]. Following receipt of written information about the intervention and the provision of informed consent, the health professionals were interviewed to determine their expert views on the feasibility of the ACP intervention and recommendations for successful implementation. Data were analyzed using thematic analysis. Results The ACP intervention was perceived to be beneficial for most older patients with multimorbidity. Effective and sustainable implementation was said to be facilitated by accurate and timely patient selection, GP buy-in, use of existing structures within health systems, multidisciplinary and integrated working, ACP nurse training, as well as patient health literacy. Barriers emerged as significant work already undertaken, increasing workload, lack of time, funding and resources, fragmented services, and geographical inequalities. Conclusions The key health professionals perceived the ACP intervention to be highly beneficial to patients, with significant potential to prevent or avoid functional decline and hospital admissions. They suggested that successful implementation of this primary care based, whole-person approach would involve integrated and multi-disciplinary working, GP buy in, patient health education, and ACP nurse training. The findings have potential implications for a full trial, and patient care and health policy. Trial registration Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06896-1.
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Affiliation(s)
- Dagmar Anna S Corry
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK. .,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Gillian Carter
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK.,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Frank Doyle
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Patrick Gillespie
- Health Economics and Policy Analysis Centre, National University of Ireland, Galway (NUI Galway), Galway, Republic of Ireland
| | - Kieran McGlade
- School of Medicine, Dentistry, and Biomedical Sciences, Dunluce Health Centre, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Peter O'Halloran
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Nina O'Neill
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK.,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland.,Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Kevin Brazil
- Centre for Evidence and Social Innovation, Queen's University Belfast, Belfast, Northern Ireland, UK. .,School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK.
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Doherty A, Moriarty F, Boland F, Clyne B, Fahey T, Kennelly S, Wallace E. Prescribing cascades in community-dwelling adults: protocol for a systematic review. HRB Open Res 2021; 4:72. [PMID: 34738069 PMCID: PMC8529400 DOI: 10.12688/hrbopenres.13345.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 04/04/2024] Open
Abstract
Introduction: Internationally, health systems face the challenge of managing a growing ageing population living with multimorbidity and polypharmacy. Potentially inappropriate prescribing is common among patients with polypharmacy, increasing the risk for adverse drug reactions (ADRs). Several prescribing indicator sets exist to improve prescribing and reduce potentially inappropriate prescribing, but do not address prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat an ADR to another prescribed medication, whether intentionally or unintentionally, and constitute an important area to consider when characterising problematic polypharmacy. This is a protocol for a systematic review examining prescribing cascades in community-dwelling adults. Methods: The review will be reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of Medline (Ovid), EMBASE, PsycINFO, CINAHL and the Cochrane Library will be conducted from inception to March 2021, using a predetermined strategy. Grey literature will be searched using Open Grey, MedNar, Dart Europe, and the Turning Research Into Practice (TRIP) databases. No restrictions will be placed on language or publication year. Inclusion criteria are: population - community-dwelling adults (≥18 years), including those in residential or nursing homes; risk - prescription medication with the potential to cause side effects; outcomes - initiation of a new medicine to 'treat' or reduce the risk of experiencing an ADR. Prospective and retrospective cohort studies, case control and case series studies will be included. Two reviewers will independently screen titles and abstracts; studies meeting inclusion criteria will undergo independent full-text screening by two reviewers. A narrative synthesis will be conducted. Study quality will be independently assessed using the relevant Joanna Briggs Institute Critical Appraisal Checklist. Discussion: This systematic review will identify examples of prescribing cascades for community-dwelling adults and contribute to developing an evidence base regarding such cascades. Registration: PROSPERO [ CRD42021243163, 31/03/2021].
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Affiliation(s)
- Ann Doherty
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Frank Moriarty
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Fiona Boland
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
- Data Science Centre, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Barbara Clyne
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Seán Kennelly
- Department of Medical Gerontology, Trinity College Dublin, Dublin 2, Ireland
- Department of Age-related Healthcare, Tallaght University Hospital, Dublin 24, Ireland
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
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Epiu I, Gandevia SC, Boswell-Ruys CL, Wallace E, Butler JE, Hudson AL. Tongue strength and swallowing dynamics in chronic obstructive pulmonary disease. ERJ Open Res 2021; 7:00192-2021. [PMID: 34262969 PMCID: PMC8273391 DOI: 10.1183/23120541.00192-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/27/2021] [Indexed: 01/25/2023] Open
Abstract
Background Swallowing disorders occur in COPD, but little is known about tongue strength and mastication. This is the first assessment in COPD of tongue strength and a test of mastication and swallowing solids (TOMASS). Methods Anterior tongue strength measures were obtained in 18 people with COPD, aged 73±11 years (mean±sd), and 19 healthy age-matched controls, aged 72±6 years. Swallowing dynamics were assessed using an eating assessment tool (EAT-10), timed water swallow test (TWST), and TOMASS. Swallowing measures were compared to an inhibitory reflex (IR) in the inspiratory muscles to airway occlusion (recorded previously in the same participants). Results Tongue strength was similar between COPD and controls (p=0.715). Self-assessed scores of dysphagia EAT-10 were higher (p=0.024) and swallowing times were prolonged for liquids (p=0.022) and solids (p=0.003) in the COPD group. During TWST, ∼30% of COPD group showed clinical signs of airway invasion (cough and wet voice), but none in the control group. For solids, the COPD group had ∼40% greater number of chews (p=0.004), and twofold-higher number of swallows (p=0.0496). Respiratory rate was 50% higher in COPD group than controls (p <0.001). The presence of an IR was not related to better swallowing outcomes, but signs of airway invasion were associated with a delayed IR. Conclusion Dysphagia in stable COPD is not due to impaired anterior tongue strength, but rather swallowing–breathing discoordination. To address dysphagia, aspiration and acute exacerbations in COPD, therapeutic targets to improve swallowing dynamics could be investigated further. In this novel study of swallowing in COPD, there was no difference in tongue strength when compared to healthy controls, and in COPD participants with airway invasion, the inhibitory reflex to airway occlusion in inspiratory muscles was delayedhttps://bit.ly/3h4EeKw
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Affiliation(s)
- Isabella Epiu
- Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales Sydney, NSW, Australia.,Prince of Wales Hospital, Sydney, NSW, Australia
| | - Simon C Gandevia
- Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales Sydney, NSW, Australia.,Prince of Wales Hospital, Sydney, NSW, Australia
| | - Claire L Boswell-Ruys
- Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales Sydney, NSW, Australia.,Prince of Wales Hospital, Sydney, NSW, Australia
| | - Emma Wallace
- Neuroscience Research Australia, Sydney, NSW, Australia.,Flinders University, Adelaide, SA, Australia
| | - Jane E Butler
- Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales Sydney, NSW, Australia
| | - Anna L Hudson
- Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales Sydney, NSW, Australia
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Alcock C, Oluwamayowa P, Wallace E. 546 QUALITY IMPROVEMENT PROJECT: IMPROVING CONTENT IN DISCHARGE SUMMARIES FOR CODING. Age Ageing 2021. [DOI: 10.1093/ageing/afab116.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Hospital coding provides a pivotal service, integral to data collection, national statistics and hospital finances. The system of accurately coding depends almost entirely on the information put into Electronic Discharge Letters (EDLs). This project aims to up skill doctors with the expertise of the coding department, so that the EDLs reflect more accurately the experiences of the patient in hospital.
Method
Cycle 1; A member from the coding department was invited to the ward once a week to join with junior doctors writing their discharge letter. The coding from the discharge letters produced during this time were compared to those immediately prior to the coding department’s involvement. Cycle 2; The lead author and a member from the coding team took a sample of 12 notes from the Ambulatory Emergency Clinic (AEC), for patients presenting in January and February of 2020.
Results
Cycle 1; there was no significant difference in the number of co-morbidities or revenue gained from EDLs written with the support of the coding team compared to doctors writing ELDs independently Cycle 2; For 9 of the 12 patients (75%), co-morbidities were added. This changed the Healthcare Resource Group coded of 5 patients, resulting in an increasing the revenue to the hospital by £757 on average. For the number of patients seen in AEC in January, this could represent £218,271 of lost revenue, in addition to other benefits of accurate record keeping.
Conclusion
The role of the physician cannot increase indefinitely, and there is a wealth of knowledge and experience to be gained from our colleagues in the coding department. This collaboration in assiduously improving the service that our patients receive brings the possibility of large financial gains as well as more accurate health care records.
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Affiliation(s)
- C Alcock
- Queen Elizabeth Hospital Kings Lynn
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46
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Wallace E, Macrae P, Huckabee ML. Objective measurement of acoustic intensity of coughing for clearance of penetration and aspiration on video-fluoroscopy. Int J Speech Lang Pathol 2021; 23:313-320. [PMID: 32664756 DOI: 10.1080/17549507.2020.1784280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE This preliminary, exploratory study evaluated the acoustic intensity of effective and ineffective clearance of penetrated and aspirated material from the laryngeal vestibule in patients with dysphagia. METHOD A lapel microphone was attached anterior to participants' tragus and recorded coughing in decibels during their videofluoroscopic swallowing studies (VFSS). RESULT Eighty-eight patients were recruited. Thirteen patients, with visible airway invasion and coughing were included in the final analysis. No coughs were effective at expelling aspirated material from the airway (n = 10). Both effective (4/7) and ineffective (3/7) coughing to penetration were recorded. The mean acoustic intensity of effective coughing to penetration was -44.0 dBFS (decibel level relative to full scale) [SD = 7.3, 95% CI = -51.14, -36.86], and ineffective coughing to penetration was only marginally lower at -42.9 dBFS [SD = 2.0, 95% CI = -45.21, -40.59]. CONCLUSION No coughs were effective at expelling aspirated material from the airway. Some coughs effectively expelled penetrated material from the airway. However, the relationship between acoustic intensity and cough effectiveness is unclear due to the limited number of observations. Given that perceptual evaluation of coughing is widely used in dysphagia clinical practice to determine cough effectiveness, this is an important area for future research.
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Affiliation(s)
- Emma Wallace
- Department of Communication Disorders, Rose Centre for Stroke Recovery and Research, University of Canterbury, Christchurch, New Zealand
| | - Phoebe Macrae
- Department of Communication Disorders, Rose Centre for Stroke Recovery and Research, University of Canterbury, Christchurch, New Zealand
| | - Maggie-Lee Huckabee
- Department of Communication Disorders, Rose Centre for Stroke Recovery and Research, University of Canterbury, Christchurch, New Zealand
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Corry DAS, Doherty J, Carter G, Doyle F, Fahey T, O’Halloran P, McGlade K, Wallace E, Brazil K. Acceptability of a nurse-led, person-centred, anticipatory care planning intervention for older people at risk of functional decline: A qualitative study. PLoS One 2021; 16:e0251978. [PMID: 34015046 PMCID: PMC8136649 DOI: 10.1371/journal.pone.0251978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/06/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND As the population of older adults increases, the complexity of care required to support those who choose to remain in the community amplifies. Anticipatory Care Planning (ACP), through earlier identification of healthcare needs, is evidenced to improve quality of life, decrease aggressive interventions, and prolong life. With patient acceptability of growing importance in the design, implementation, and evaluation of healthcare interventions, this study reports on the acceptability of a primary care based ACP intervention on the island of Ireland. METHODS As part of the evaluation of a feasibility cluster randomized controlled trial (cRCT) testing an ACP intervention for older people at risk of functional decline, intervention participants [n = 34] were interviewed in their homes at 10-week follow-up to determine acceptability. The intervention consisted of home visits by specifically trained registered nurses who assessed participants' health, discussed their health goals and plans, and devised an anticipatory care plan in collaboration with participants' GPs and adjunct clinical pharmacist. Thematic analysis was employed to analyze interview data. The feasibility cRCT involved eight general practitioner (GP) practices as cluster sites, stratified by jurisdiction, four in Northern Ireland (NI) (two intervention, two control), and four in the Republic of Ireland (ROI) (two intervention, two control). Participants were assessed for risk of functional decline. A total of 34 patients received the intervention and 31 received usual care. FINDINGS Thematic analysis resulted in five main themes: timing of intervention, understanding of ACP, personality & individual differences, loneliness & social isolation, and views on healthcare provision. These map across the Four Factor Model of Acceptability ('4FMA'), a newly developed conceptual framework comprising four components: intervention factors, personal factors, social support factors, and healthcare provision factors. CONCLUSION Acceptability of this primary care based ACP intervention was high, with nurses' home visits, GP anchorage, multidisciplinary working, personalized approach, and active listening regarded as beneficial. Appropriate timing, and patient health education emerged as vital.
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Affiliation(s)
- Dagmar A. S. Corry
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Julie Doherty
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Gillian Carter
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Frank Doyle
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Peter O’Halloran
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Kieran McGlade
- School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, Dunluce Health Centre, Belfast, Northern Ireland, United Kingdom
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
- Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Kevin Brazil
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
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O'Brien E, Clyne B, Smith SM, O'Herlihy N, Harkins V, Wallace E. A scoping review protocol of evidence-based guidance published by general practitioner professional organisations. HRB Open Res 2021; 4:53. [DOI: 10.12688/hrbopenres.13268.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: General practitioners (GPs) strive to use a patient centred approach to achieve shared decision making by integrating clinical evidence, clinical judgement, and patient priorities. This protocol outlines a scoping review to identify what evidence-based guidance is produced by general practitioner professional organisations internationally to support general practice clinical decision making. Methods: This scoping review will be conducted using the framework proposed by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR), will be used to guide the reporting. Two researchers will search electronic databases (Medline, Embase, Cochrane Library and Scopus), grey literature sources and contact international GP professional organisations directly to identify appropriate studies for inclusion. Key information will be categorised and classified to generate a summary of the methods used internationally to develop and implement evidence-based guides for general practitioners and a narrative synthesis will be conducted. Conclusions: This scoping review will identify the role of GP professional organisations in generating, endorsing and/or disseminating evidence-based guidance for supporting general practitioner’s clinical decision making to benefit patient care.
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Walsh ME, Cronin S, Boland F, Ebell MH, Fahey T, Wallace E. Geographical variation of emergency hospital admissions for ambulatory care sensitive conditions in older adults in Ireland 2012-2016. BMJ Open 2021; 11:e042779. [PMID: 33952537 PMCID: PMC8103372 DOI: 10.1136/bmjopen-2020-042779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Ambulatory care sensitive (ACS) conditions are those for which intensified primary care management could potentially prevent emergency admissions. This study aimed to quantify geographical variation in emergency admissions with ACS conditions in older adults and explore factors influencing variation. DESIGN Repeated cross-sectional study. SETTING 34 public hospitals in the Ireland. PARTICIPANTS Adults aged ≥65 years hospitalised for seven ACS conditions between 2012 and 2016 (chronic obstructive pulmonary disease, congestive heart failure (CHF), diabetes, angina, pyelonephritis/urinary tract infections (UTIs), dehydration and pneumonia). PRIMARY OUTCOME MEASURE Age and sex standardised emergency admission rates (SARs) per 1000 older adults. ANALYSIS Age and sex SARs were calculated for 21 geographical areas. Extremal quotients and systematic components of variance (SCV) quantified variation. Spatial regression analyses was conducted for SARs with unemployment, urban population proportion, hospital turnover, supply of general practitioners (GPs), and supply of hospital-based specialists as explanatory variables. RESULTS Over time, an increase in UTI/pyelonephritis SARs was seen while SARs for angina and CHF decreased. Geographic variation was moderate overall and high for dehydration and angina (SCV=11.7-50.0). For all conditions combined, multivariable analysis showed lower urban population (adjusted coefficient: -2.2 (-3.4 to -0.9, p<0.01)), lower GP supply (adjusted coefficient: -5.5 (-8.2 to -2.9, p<0.01)) and higher geriatrician supply (adjusted coefficient: 3.7 (0.5 to 6.9, p=0.02)) were associated with higher SARs. CONCLUSIONS Future research should evaluate methods of preventing admissions for ACS conditions among older adults, including how resources are allocated at a local level.
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Affiliation(s)
- Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sinead Cronin
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark H Ebell
- Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Abstract
BACKGROUND Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. The term comorbidity is also used but this is now taken to mean that there is a defined index condition with other linked conditions, for example diabetes and cardiovascular disease. It is also used when there are combinations of defined conditions that commonly co-exist, for example diabetes and depression. While this is not a new phenomenon, there is greater recognition of its impact and the importance of improving outcomes for individuals affected. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. OBJECTIVES To determine the effectiveness of health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. SEARCH METHODS We searched MEDLINE, EMBASE, CINAHL and seven other databases to 28 September 2015. We also searched grey literature and consulted experts in the field for completed or ongoing studies. SELECTION CRITERIA Two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after studies (CBAs), and interrupted time series analyses (ITS) evaluating interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. This includes studies where participants can have combinations of any condition or have combinations of pre-specified common conditions (comorbidity), for example, hypertension and cardiovascular disease. The comparison was usual care as delivered in that setting. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies, evaluated study quality, and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of the results where possible and carried out a narrative synthesis for the remainder of the results. We present the results in a 'Summary of findings' table and tabular format to show effect sizes across all outcome types. MAIN RESULTS We identified 17 RCTs examining a range of complex interventions for people with multimorbidity. Nine studies focused on defined comorbid conditions with an emphasis on depression, diabetes and cardiovascular disease. The remaining studies focused on multimorbidity, generally in older people. In 11 studies, the predominant intervention element was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In six studies, the interventions were predominantly patient-oriented, for example, educational or self-management support-type interventions delivered directly to participants. Overall our confidence in the results regarding the effectiveness of interventions ranged from low to high certainty. There was little or no difference in clinical outcomes (based on moderate certainty evidence). Mental health outcomes improved (based on high certainty evidence) and there were modest reductions in mean depression scores for the comorbidity studies that targeted participants with depression (standardized mean difference (SMD) -0.41, 95% confidence interval (CI) -0.63 to -0.2). There was probably a small improvement in patient-reported outcomes (moderate certainty evidence). The intervention may make little or no difference to health service use (low certainty evidence), may slightly improve medication adherence (low certainty evidence), probably slightly improves patient-related health behaviours (moderate certainty evidence), and probably improves provider behaviour in terms of prescribing behaviour and quality of care (moderate certainty evidence). Cost data were limited. AUTHORS' CONCLUSIONS This review identifies the emerging evidence to support policy for the management of people with multimorbidity and common comorbidities in primary care and community settings. There are remaining uncertainties about the effectiveness of interventions for people with multimorbidity in general due to the relatively small number of RCTs conducted in this area to date, with mixed findings overall. It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future updates. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression in people with co-morbidity.
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Affiliation(s)
- Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, RCSI Medical School, Dublin 2, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, RCSI Medical School, Dublin 2, Ireland
| | - Tom O'Dowd
- Department of Public Health and Primary Care, Trinity College Centre for Health Sciences, Dublin, Ireland
| | - Martin Fortin
- Department of Family Medicine, University of Sherbrooke, Quebec, Canada
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