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Background: The CELTIC ranges project aims to deliver a comprehensive range of reference intervals for commonly ordered laboratory investigations suitable for use in an Irish population as well as enabling comparison with relevant international studies. In this paper, we describe our methodology used throughout the entire project and present paediatric reference intervals for renal profile tests in plasma (sodium, potassium, urea and creatinine). Methods: 1023 children aged up to 17 years were recruited from our hospital's general practitioner paediatric phlebotomy clinic. Clinical chemistry analyses were performed on the Roche modular system and statistical analysis was completed in line with CLSI guideline EP28-A3c. Results: The plasma reference interval for sodium for ages 0.45–16.99 years was 137–143 mmol/L in 1000 subjects (combined genders). For plasma potassium, the corresponding ranges between 1 and 16.99 years (combined genders) were 3.6–4.8 mmol/L. Apart from neonates and in keeping with other studies, age partitioning for electrolytes was not required. Data for plasma creatinine (enzymatic methodology) and urea is also presented and, as anticipated, required partitioning for both age and gender. Conclusions: Our renal profile findings are broadly consistent with those of international studies, for example, CALIPER, HAPPI, NORDIC, PRINCE and KiGGs. Moreover, the CELTIC ranges study is also based on over 1000 subjects whose samples were analysed on the widely used Roche modular analytics system. We also expect the findings will improve knowledge of children's metabolic health in Ireland. [ABSTRACT FROM AUTHOR]

Introduction: The Irish Medical Council has regulated mandatory continuing professional development (CPD) for doctors since 2011 to enhance the quality and safety of Irish healthcare. The Irish College of General Practitioners (ICGP), as the professional body for general practitioners (GPs) in Ireland, operates a Professional Competence Scheme (PCS) for doctors working in general practice. As PCS evolves over time, it is important to measure the impact of mandatory CPD on patient care. The ICGP undertook this study to answer the research question: Does CPD enhance patient care? Research has been conducted on the impact of CPD on the medical profession, both in Ireland and abroad, on GP engagement with existing CPD supports and on the impact of CPD for GPs in other countries. To date, no study has been carried out in Ireland on GP views on the impact of mandatory CPD on patient care or on which type of CPD activity is perceived to be the most effective in this regard. Methods: All PCS enrollees on the 2018/2019 year who had provided an email address (n = 4,415) were asked to complete an anonymous online survey available in April and May 2019. The survey aimed to obtain feedback on existing CPD supports, enhancement of CPD supports, CPD impact on general practice and on patient care. The survey questions which related specifically to patient care were used to inform this paper. Results: A total of 1,233 (27.9%) PCS enrolees participated in the survey. Overall, 73.9% (n = 836) of respondents agreed that CPD assisted them in improving the quality of patient care with females significantly more likely to consider that CPD improved patient care. A total of 74.9% (n = 848) reported changes to patient management as a result of CPD activity and over half (56.4%; n = 464) of these believed that external CPD activity (courses/conferences) had the most potential to benefit their patient care, however, differences were observed across gender and age group. Conclusion: The majority of GPs who completed the survey found CPD engagement beneficial to their patient care. The majority of respondents agree that peer engagement activities are most likely to impact patient care thus demonstrating that mandatory CPD has been successfully implemented in this respect in Irish general practice. However, there is a difference in response to the various CPD formats across different demographic cohorts and this should be considered when designing the format of educational activities. [ABSTRACT FROM AUTHOR]

Background: There is limited United Kingdom (UK) literature on general practice-based pharmacists' (PBPs') role evolution and few studies have explored general practitioners' (GPs') experiences on pharmacist integration into general practice. Therefore, this study aimed to investigate GPs' experiences with, views of, and attitudes towards PBPs in Northern Ireland (NI). Methods: A paper-based self-administered questionnaire comprising four sections was mailed in 2019 to 329 general practices across NI and was completed by one GP in every practice who had most contact with the PBP. Descriptive analyses were used and responses to open-ended questions were analysed thematically. Results: The response rate was 61.7% (203/329). There was at least one PBP per general practice. All GPs had face-to-face meetings with PBPs, with three-quarters (78.7%, n = 159) meeting with the PBP more than once a week. Approximately two-thirds of GPs (62.4%, n = 126) reported that PBPs were qualified as independent prescribers, and 76.2% of these (n = 96/126) indicated that prescribers were currently prescribing for patients. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n = 162) and knowledge (87.0%, n = 167) to provide safe and effective care for patients. However, 31.1% (n = 61) stated that PBPs only sometimes had the confidence to make clinical decisions. The majority of GPs (> 85%) displayed largely positive attitudes towards collaboration with PBPs. Most GPs agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n = 192) and can provide a better link between general practices and community pharmacists (96.1%, n = 194). However, 24.8% of GPs (n = 50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. An evaluation of the free-text comments indicated that GPs were in favour of more PBP sessions and full-time posts. Conclusion: Most GPs had positive views of, and attitudes towards, PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Exploring PBPs', community pharmacists' and patients' views of this role in general practice is required to corroborate study findings. [ABSTRACT FROM AUTHOR]

The Irish General Practitioner Training (GP) Programme is currently moving to Competency-Based Medical Education (CBME), facilitated by Programmatic Assessment (PA) and Entrustable Professional Activities (EPAs). These new assessment and feedback mechanisms may provide a rich and much sought-after dataset. However, given the possible number of feedback and assessment events, and the variety of modalities used, aggregating and interpreting these can be costly and difficult. Dashboard implementations (DI) have been purposed as a solution to bridge the gap between the large datasets and the training community at all levels. To explore the Irish GP training community's perceptions on how an EPAs DI could facilitate the delivery of GP training in Ireland. A qualitative approach was taken, using a focus group representative of different groups in the training community. Concurrently, an EPAs DI was developed. Focus group transcripts were analysed in an iterative fashion using Template Analysis to generate themes and subthemes. Numerous advantages were seen in relation to the implementation of an EPAs DI around entrustment decisions, constructive alignment and summative decision-making. These advantages, however, need to be tempered with the realisation that the EPAs DI is not and should not be misinterpreted as being the learning analytic panacea for GP training. This paper outlines the perceptions from a postgraduate medical education training community on an EPAs DI, which would be applicable to other training communities considering introducing similar mechanisms. [ABSTRACT FROM AUTHOR]

This paper analyses the effect accessibility has on General Practitioner (GP) utilisation rates at the sub-national level for Ireland. Specifically, the aim of this paper is to estimate whether there is an urban–rural differential in GP utilisation rates. We do this by simulating micro-level healthcare data. Using this synthetic data, simple logit models are employed to estimate the likelihood that individuals in different jurisdictions will attend a GP surgery. These individual logit estimates are then inputted into a spatial interaction model to highlight areas with low GP accessibility given their health status. The policy implications of these results are discussed in relation to both the healthcare literature and current Irish healthcare policy. [ABSTRACT FROM AUTHOR]

Purpose: The assessment and management of prisoners on hunger strikes in a custodial setting is complex. There is limited clinical guidance available for psychiatrists to draw upon in such cases. The purpose of this paper is to develop a management algorithm through expert elicitation to inform the psychiatric care of prisoners on a hunger strike.Design/methodology/approach: A Delphi method was used to elicit views from Irish forensic psychiatrists, a legal expert and an expert in ethics using a structured questionnaire. Themes were extracted from the results of the questionnaire to propose a management algorithm. A consensus was reached on management considerations.Findings: Five consultant forensic psychiatrists, a legal expert and an expert on psychiatric ethics ( n=7) consented to participation, with a subsequent response rate of 71.4 per cent. Consensus was achieved on a proposed management algorithm. Assessment for mental disorder, capacity to refuse food and motivation for food refusal are seen as key psychiatric tasks. The need to work closely with the prison general practitioner and the value of multidisciplinary working and legal advice are described. Relevant aspects of law included mental health, criminal law (insanity) and capacity legislation.Originality/value: This study outlines a management algorithm for the psychiatric assessment and management of prisoners on a hunger strike, a subject about which there is limited guidance to date. Although written from an Irish perspective, this study outlines key considerations for psychiatrists in keeping with international guidance and therefore may be generalisable to other jurisdictions. [ABSTRACT FROM AUTHOR]

Aim Clinical handover at the point of discharge is critically important. It generally occurs through a written document, usually in the form of a discharge summary. Hospital discharge summaries contribute to continuity of care for patients who leave hospital and who may require care in the community provided by their GP. They must be accurate, valid, reliable, timely, legible and complete. The aim of this study was to investigate GPs' perceptions of the content of discharge summaries generated by emergency advanced nurse practitioners (EANPs). Method A cross-sectional descriptive survey design was used and a questionnaire was distributed to 120 GPs. Raw statistical data were analysed using SPSS v22 while the qualitative data from the open-ended questions were manually analysed. Findings Most GPs were satisfied with the EANPs' discharge summary letters. However, this study supports previous papers that identified deficits in communication between secondary care and GPs. Conclusion There is a need to refine discharge summaries to create an enhanced structured discharge summary template that can be used by all disciplines. [ABSTRACT FROM AUTHOR]

Purpose There has been an increase in the use of registers and record linkages to study migrant mental health. However, the accuracy of these registers and the degree to which they are representative of the migrant population in Northern Ireland (NI) are unclear. The purpose of this paper is to explore: the coverage of the NI migrant population in general practitioner (GP) data and Census records; the issues faced by migrants in terms of registering and accessing the local health system; and the reporting of racial hate crimes against migrants to police.Design/methodology/approach Two focus groups of professionals (n=17) who worked with migrants were conducted. Group discussions were guided by a research-informed topic guide, and the data were analysed using thematic analysis.Findings Three main themes emerged: issues with the use of GP registration, Census and hate crime data for researching migrant mental health; barriers to health service use (e.g. low cultural awareness among health staff and access to interpreters); and risk factor exposure and mental health status in migrant communities (e.g. poverty, isolation and poor working conditions).Originality/value Record linkage and registry studies of migrant health and well-being using Census and health service sources need to be mindful of the likelihood that some migrants may be missed. The possible underrepresentation of migrants in health registers may be explained by reduced use of such services which may be caused my encountering staff with limited cultural competency and the inability to access an interpreter promptly. [ABSTRACT FROM AUTHOR]

Background: The inverse care law states that availability of good medical care varies inversely with the need for it in the population served. In 2019, the main medical union and the Department of Health in the Republic of Ireland (RoI), agreed on funding a social deprivation practice grant for general practices in urban deprived areas. Aim: To examine the implementation and impact of the social deprivation practice grant in participating general practices. Design & setting: A mixed-methods study with sequential design based in Irish general practice. Method: Data were collected using a questionnaire and online semi-structured interviews with GPs and practice staff. Data were analysed separately, and the findings compared to examine the extent to which they converged or diverged. Results: There were 25 survey responses and nine interviews. All practices reported the grant was beneficial and most practices utilised the grant to fund additional doctor hours (17/25). Both surveys and interviews indicated that a small amount of additional funding allowed additional clinical need in areas of deprivation to be addressed, but there were some barriers identified in accessing the grant and implementing planned expenditure. Conclusion: Delivery of health care in areas of socioeconomic deprivation presents significant challenges. While there were some problems with implementation, the introduction of a small, targeted grant for general practices in areas of social deprivation allowed those practices to enhance their services, with tailored initiatives seeking to meet the needs of their patient populations. [ABSTRACT FROM AUTHOR]

The use of direct out-of-pocket payments to finance general practitioner (GP) care by the majority of the population in Ireland is unusual in a European context. Currently, approximately 40% of the population have means-tested access to free GP care, while the remainder must pay the full out-of-pocket cost. In this paper, we use data from The Irish Longitudinal Study on Ageing (TILDA) to examine the impact of the current system of public healthcare entitlements on GP utilisation among the older population. Using difference-in-difference propensity score matching methods, we find significant effects of changes in public healthcare entitlements on GP utilisation (i.e. introducing user fees reduces utilisation, while removing them increases utilisation). There is limited evidence of offset effects on other types of healthcare utilisation. The results have direct implications for current Irish health policy, and add to the international literature on the effects of insurance on healthcare utilisation. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background There is a global shortage of medical manpower. One approach to resolve such deficiencies is to effectively promote health careers to high-school students. Summer programmes held by medical faculties provide ideal opportunities for pre-medical students to examine the possible career opportunities in medicine. Methods The Royal College of Surgeons in Ireland has recently launched a ' Mini- Medical School' ( MMS) programme for suburban and rural high-school students in the South Eastern Region of Ireland. This paper illustrates the MMS project and describes the participants' reaction and evaluation of the programme and the factors influencing their desire to practise medicine in future. Results A total of 90 students completed the online survey (response rate 75%). Eighty-two per cent of the students indicated definitive and strong desire to study medicine after secondary school. There was no difference in interest between male and female students ( P-value 0.665). The main factors influencing this interest were personal. Forty-four per cent of participants attributed this to the opportunity to help others while 30% to the intellectual challenge, whereas family, friends and other factors accounted for the rest of influential factors to study medicine. The majority agreed (60%) that the programme was quite accessible and easy to have a place. Opinions about the content of the programme focussed mainly on the interactive sessions. Forty-seven per cent liked the live patient-doctor interaction session the most, and 43% found the live video session very informative. Conclusion The MMS is a highly effective platform for both the medical specialties and the high-school students. [ABSTRACT FROM AUTHOR]

An important element of the process by which new drugs achieve widespread use is their adoption by GPs. In this paper, we explore the factors that shape the timing of the first prescription of six new drugs by General Practitioners in Ireland. Our analysis is based on a dataset that matches prescription data with data on GP characteristics. We then use duration analysis to explore both equilibrium and non-equilibrium determinants of prescribing innovation. Our study highlights a range of commonalities across all of the drugs considered and suggests the importance of GP and practice characteristics in shaping prescribing decisions. We also find strongly significant, and consistently signed, stock and order effects across these drugs: GPs who have a track record of early adoption tend also to be early adopters of other new drugs; and, the larger the proportion of GPs which have already adopted a new drug the slower is subsequent adoption. Epidemic and learning effects are also evident with slower adoption by rural practices and among those GPs with narrower prescribing portfolios. [ABSTRACT FROM AUTHOR]

Abstract: Internationally, there is extensive empirical evidence that a strong primary care-led health system is associated with improved health outcomes, increased quality of care, decreased health inequalities and lower overall health-care costs. Within primary care, factors influencing access to, and utilisation of, general practitioner (GP) services have been widely examined and this paper focuses on the role of user financial incentives. In particular, user charges for health care have been observed to deter health-care utilisation. Relative to other countries, the Irish health-care system is unusual in that the majority of the population are required to pay out-of-pocket for GP care. However, in 2005 the Irish government extended eligibility for free GP care to a further small subset of the population. Using micro-data from a nationally representative survey of the population in 2007, this paper analyses the impact of differential coverage of free GP services on GP utilisation in Ireland. Results from multivariate regression analysis indicate that GP utilisation is significantly more likely in the context of free GP care, controlling for a range of demographic, socio-economic and health factors. Interpretation of the results for the new category of coverage is complicated by possible pent-up demand and selection effects. [Copyright &y& Elsevier]

Background: Electronic clinical decision support (CDS) is increasingly establishing its role in evidence-based clinical practice. Considerable evidence supports its enhancement of efficiency in e-Prescribing, but some controversy remains. This study evaluated the practicality and identified the perceived benefits of, and barriers to, its future adoption in the West of Ireland. Methods: This cross sectional study was carried out by means of a 27-part questionnaire sent to 262 registered general practitioners in Counties Galway, Mayo and Roscommon. The survey domains encompassed general information of individual's practice, current use of CDS and the practitioner's attitudes towards adoption of CDS-eP. Descriptive and inferential analyses were performed to analyse the data collected. Results: The overall response rate was 37%. Nearly 92% of respondents employed electronic medical records in their practice. The majority acknowledged the value of electronic CDS in improving prescribing quality (71%) and reducing prescribing errors (84%). Despite a high degree of unfamiliarity (73%), the practitioners were open to the use of CDS-eP (94%) and willing to invest greater resources for its implementation (62%). Lack of a strategic implementation plan (78%) is the main perceived barrier to the incorporation of CDS-eP into clinical practice, followed by i) lack of financial incentives (70%), ii) lack of standardized product software (61%), iii) high sensitivity of drug-drug interaction or medication allergy markers (46%), iv) concern about overriding physicians' prescribing decisions(44%) and v) lack of convincing evidence on the systems' effectiveness (22%). Conclusions: Despite favourable attitudes towards the adoption of CDS-eP, multiple perceived barriers impede its incorporation into clinical practice. These merit further exploration, taking into consideration the structure of the Irish primary health care system, before CDS-eP can be recommended for routine clinical use in the West of Ireland. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Opiate use disorder is a common condition in healthcare services in Ireland, where over 200 opiate overdose deaths occur annually. There is limited addiction medicine education at undergraduate level and medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdose presentations. Therefore, we examined final-year medical students' learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment.Methods: We administered an anonymous paper-based survey to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin, Ireland. Results were compared with parallel surveys of General Practitioners (GPs) and GP trainees.Results: A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of its care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).Conclusions: Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care. [ABSTRACT FROM AUTHOR]

The successful implementation of the ongoing roll-out of free GP care for all private patients in Ireland, begun in 2015, requires an estimate of its impact on GP utilisation. However, estimates of this impact vary widely. For example, a recent study based on administrative records of six GP practices, predicts an extra 4.4 million GP visits. This paper argues that little reliance should be placed on this estimate due to methodological and sample selection issues, as well as the use of demonstrably inappropriate assumptions. Instead, more reliance should be placed on estimates derived from retrospective self-reporting surveys (e.g. Growing Up in Ireland, the Irish Longitudinal Study on Ageing) which suggest that extending free GP care to all private patients is likely to result in an increase of around 2.5 million GP visits. The increase in demand for GP services occasioned by free GP care feeds into the wider debate about the enhanced role of primary care in Ireland and the corresponding increase in funding. [ABSTRACT FROM AUTHOR]

Background: In 2018, the right to lawful abortion in the Republic of Ireland significantly expanded, and service provision commenced on 1 January, 2019. Community provision of early medical abortion to 9 weeks plus 6 days gestation delivered by General Practitioners constitutes the backbone of the Irish abortion policy implementation. We conducted a study in 2020–2021 to examine the barriers and facilitators of the Irish abortion policy implementation. Methods: We collected data using qualitative in-depth interviews (IDIs) which were conducted in-person or remotely. We coded and analysed interview transcripts following the grounded theory approach. Results: We collected 108 IDIs in Ireland from May 2020 to March 2021. This article draws on 79 IDIs with three participant samples directly relevant to the community model of care: (a) 27 key informants involved in the abortion policy development and implementation representing government healthcare administration, medical professionals, and advocacy organisations, (b) 22 healthcare providers involved in abortion provision in community settings, and (c) 30 service users who sought abortion services in 2020. Facilitators of community-based abortion provision have been: a collaborative approach between the Irish government and the medical community to develop the model of care, and strong support systems for providers. The MyOptions helpline for service users is a successful national referral model. The main barriers to provision are the mandatory 3-day wait, unclear or slow referral pathways from primary to hospital care, barriers for migrants, and a shortage and incomplete geographic distribution of providers, especially in rural areas. Conclusions: We conclude that access to abortion care in Ireland has been greatly expanded since the policy implementation in 2019. The community delivery of care and the national helpline constitute key features of the Irish abortion policy implementation that could be duplicated in other contexts and countries. Several challenges to full abortion policy implementation remain. [ABSTRACT FROM AUTHOR]

Abstract: In the Republic of Ireland, approximately 30% of the population (‘medical card patients’) are entitled to free general practice services. Eligibility is determined primarily on the basis of an income means test. The remaining 70% of the population (‘private patients’) must pay the full cost of all general practitioner (GP) consultations. From July 2001, all those over 70 years of age are also entitled to a medical card, regardless of income. This change in the pricing of GP services in the Republic of Ireland in 2001 provides a natural experiment that allows for an examination of the influence of economic incentives on GP visiting behaviour. The purpose of this paper is to examine whether this change in pricing for GP care for those over 70 years of age in Ireland led to an increase in the utilisation of GP services among this group. Using data from two nationally representative surveys of the population over the age of 65 before and after the policy change, difference-in-difference two-step models of GP visiting behaviour are estimated. The results indicate that, while there is some limited evidence in favour of an increase in the probability of seeking GP care among those over 70 years of age after the policy change, there is no significant effect on the frequency of visits. Differences in the incentives facing both patients and GPs after the policy change can explain the latter result. [Copyright &y& Elsevier]

Background The diagnosis of dementia poses difficulties for general practitioners (GPs) particularly when access to specialist diagnostic services is delayed. Ireland is soon to witness an increase in numbers of people presenting with dementia, yet little is known about the service needs of GPs when attempting to diagnose dementia. Objectives To detail the service needs of GPs, especially their training needs, access to diagnostic resources such as CT and MRI brain scans and access to specialist services such as Old Age Psychiatry (OAP), Geriatric Medicine (GM) and Neuropsychology (NP). Methods The paper is based on survey data collected from a sample of GPs (n = 300) registered with the Irish College of General Practitioners (ICGP) and on qualitative data collected from a Focus Group (n = 7). Results GPs were more likely to blame themselves than either the health care system, their patients or family members for the late presentation of dementia in primary care. Stigma was a major obstacle preventing GPs from being more proactive in this area. Rural GPs felt geographically disadvantaged accessing diagnostic services and both rural and urban GPs experienced considerable time delays accessing specialist diagnostic services. Conclusions Findings provide compelling evidence that training and access to diagnostic services are only two of several different structural and ideological obstacles that GPs encounter when attempting to diagnose dementia. Future educational supports for GPs need to be developed which concentrate on these areas.Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The determinants of general practitioner (GP) visiting patterns in Ireland, in particular the role of eligibility for free GP care, are examined using microdata from a nationally representative survey of the population in 2001. Whereas most studies find that need factors such as age and health status are most important in determining GP visiting rates, the Irish situation is complicated by the distinction between medical card patients, who receive free GP visits, and private patients, who must pay for each visit. Controlling for a variety of need-related and other factors, the results show that health status and medical card eligibility are consistently most important in explaining differences in GP visiting patterns. The medical card result is particularly noteworthy; even when differences in age and other observable characteristics between medical card and private patients are taken into account, medical card patients are both more likely than private patients to visit their GP, and they visit more frequently when they do. In addition, we investigated whether individuals just above the income threshold for a medical card are disadvantaged in terms of accessing GP services in comparison with other private patients on higher incomes. We found that there is little significant difference among private patients in GP visiting rates as we move up the income distribution. [ABSTRACT FROM AUTHOR]

This paper analyses the pure time-series properties of doctors' fees in Ireland to assess whether a structural change in the series is observed at the time of the change in reimbursement in 1989. Such a break would be consistent with doctors responding to the reimbursement change in a manner predicted by supplier-induced-demand behaviour and would provide indirect evidence that such inducement had taken place. Structural change is assessed on the basis of CUSUM and CUSUMSQ tests. The data is also analysed for the presence of unusually influential observations. In neither case are the results consistent with a break around the time of the introduction of the change. [ABSTRACT FROM AUTHOR]

Aims: For the general dental practitioner (GDP) coronectomy may be a treatment option that is discussed with a patient prior to referral to a specialist in primary or secondary care for management of problematic mandibular third molars. The purpose of this study was to examine the variance between coronectomy prescription between GDPs compared to specialist clinicians when assessing cases for coronectomy using plain view radiographs. Methods: An online survey was completed by 50 GDPs across the UK. This survey had also been completed by 25 specialist oral and maxillofacial or oral surgery clinicians of varying levels of experience from six different units across the UK and the Republic of Ireland. Results: Results were compared and, whilst agreement between GDPs was higher in coronectomies prescribed, there was a significantly larger number of coronectomies prescribed in the GDP group. Conclusions: The increased number of coronectomies prescribed by the GDP group compared to the specialist group could reflect a lack of experience in the regular assessment of mandibular third molars or a clinician being more aware of the litigious climate of dentistry when based in primary dental care. [ABSTRACT FROM AUTHOR]

Background: Urgent out-of-hours medical care is necessary to ensure people can remain living at home into older age. However, older people experience multiple barriers to using out-of-hours services including poor awareness about the general practitioner (GP) out-of-hours (GPOOH) service and how to access it. In particular, older people are reluctant users of GPOOH services because they expect either their symptoms will not be taken seriously or they will simply be referred to hospital accident and emergency services. The aim of this study was to examine if this expectation was borne out in the manner of GPOOH service provision.Objective: The objective was to establish the urgency categorization and management of calls to GPOOH , for community dwelling older people in Ireland.Methods: An 8-week sample of 770 calls, for people over 65 years, to a GPOOH service in Ireland, was analysed using Excel and Nvivo software.Results: Urgency categorization of older people shows 40% of calls categorized as urgent. Recognition of the severity of symptoms, prompting calls to the GPOOH service, is also reflected in a quarter of callers receiving a home visit by the GP and referral of a third of calls to emergency services. The findings also show widespread reliance on another person to negotiate the GPOOH system, with a third party making 70% of calls on behalf of the older person seeking care.Conclusion: Older people are in urgent need of medical services when they contact GPOOH service, which plays an effective and patient-centred gatekeeping role, particularly directing the oldest old to the appropriate level of care outside GP office hours. The promotion of GPOOH services should be enhanced to ensure older people understand their role in supporting community living. [ABSTRACT FROM AUTHOR]

Background: There is some evidence to suggest that pharmacists integrated into primary care improves patient outcomes and prescribing quality. Despite this growing evidence, there is a lack of detail about the context of the role.Objective: To explore the implementation of The General Practice Pharmacist (GPP) intervention (pharmacists integrating into general practice within a non-randomized pilot study in Ireland), the experiences of study participants and lessons for future implementation.Design and Setting: Process evaluation with a descriptive qualitative approach conducted in four purposively selected GP practices.Methods: A process evaluation with a descriptive qualitative approach was conducted in four purposively selected GP practices. Semi-structured interviews were conducted, transcribed verbatim and analysed using a thematic analysis.Results: Twenty-three participants (three pharmacists, four GPs, four patients, four practice nurses, four practice managers and four practice administrators) were interviewed. Themes reported include day-to-day practicalities (incorporating location and space, systems and procedures and pharmacists' tasks), relationships and communication (incorporating GP/pharmacist mode of communication, mutual trust and respect, relationship with other practice staff and with patients) and role perception (incorporating shared goals, professional rewards, scope of practice and logistics).Conclusions: Pharmacists working within the general practice team have potential to improve prescribing quality. This process evaluation found that a pharmacist joining the general practice team was well accepted by the GP and practice staff and effective interprofessional relationships were described. Patients were less clear of the overall benefits. Important barriers (such as funding, infrastructure and workload) and facilitators (such as teamwork and integration) to the intervention were identified which will be incorporated into a pilot cluster randomized controlled trial. [ABSTRACT FROM AUTHOR]

Background: Medication error at transitions of care is common. The implementation of medicines reconciliation processes to improve this issue has been recommended by many regulatory and safety organisations. The aim of this study was to gain insight from healthcare professionals on the barriers and facilitators to the medicines reconciliation implementation process. Methods: Semi-structured interviews were conducted in Ireland with a wide range of healthcare professionals (HCPs) involved with medicines reconciliation at transitions of care. Thematic analysis was undertaken using an adaptation of a combined theoretical framework of Grol, Cabana and Sluisveld to classify the barriers and facilitators to implementation of medicines reconciliation. Results: Thirty-five participants were interviewed, including eleven community pharmacists (CPs), eight hospital pharmacists (HPs), nine hospital consultants (HCs), five general practitioners (GPs), and two non-consultant hospital doctors (NCHDs). Themes were categorized into barriers and facilitators. Barriers included resistance from existing professional cultures, staff interest and training, poor communication and minimal information and communications technology (ICT) support. Solutions (facilitators) suggested included supporting effective multidisciplinary teams, greater involvement of pharmacists in medicines reconciliation, ICT solutions (linked prescribing databases, decision support systems) and increased funding to provide additional (e.g. admission and discharge reconciliation) and more advanced services (e.g. community pharmacist delivered medicines use review). Conclusions: Medicines reconciliation is advocated as a solution to the known problem of medication error at transitions of care. This study identifies the key challenges and potential solutions that policy makers, managers and HCPs should consider when reviewing the practices and processes of medicines reconciliation in their own organisations. [ABSTRACT FROM AUTHOR]

Background: The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken. Methods: Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12–18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly. Results: On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month. Conclusions: Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely. [ABSTRACT FROM AUTHOR]

AUTH Why you should read this article: • To be aware of the benefits of timely diagnosis and disclosure of dementia for patients and their families • To gain knowledge of the enablers and barriers to timely diagnosis of dementia in primary care • To understand the expanding role of nurses practising in primary care and community mental health services in the care, diagnosis and management of patients with dementia Background: Timely diagnosis involves making and sharing a diagnosis at a time and in a way that are most appropriate for the physical, emotional, medical and other needs of the patient and their family. GPs are often the first point of contact for people who are concerned that they may have dementia and, therefore, have an essential role in the timely diagnosis and disclosure of this condition. Aim: To explore the views of GPs in relation to the timely diagnosis and disclosure of dementia for patients and their families in primary care. Method: This was a small-scale qualitative study in which a survey questionnaire was sent to GPs practising in one health service executive locality in the west of Ireland. A total of ten GPs completed the questionnaire, and descriptive content analysis was used to explore their responses. Findings: Enablers of timely diagnosis and disclosure of dementia included: patient and family awareness of dementia; access to diagnostic resources and multidisciplinary assessments; having sufficient time to disclose the diagnosis sensitively; and the availability of community-based, dementia-specific support. Barriers to timely diagnosis and disclosure of dementia included: diagnostic uncertainty; concerns about misdiagnosing patients; and concerns about the stigma associated with dementia and how patients and their families might react to disclosure of such a diagnosis. There was widespread agreement among the GPs that timely diagnosis and disclosure benefit patients and their families, but also some scepticism regarding the efficacy of diagnosis and treatment for dementia (therapeutic nihilism). Conclusion: The diagnosis and disclosure of dementia in primary care could be enhanced by improving GPs' access to resources such as multidisciplinary assessments, memory clinics and community-based support schemes. Primary care and community mental health nurses have an important role in providing expertise to GPs and support to patients and their families. [ABSTRACT FROM AUTHOR]

Background: The treatment and management of long-term health conditions is the greatest challenge facing health systems around the world today. Innovative approaches to patient care in the community such as Anticipatory Care Planning (ACP), which seek to help with the provision of high-quality comprehensive care to older adults at risk of functional decline, require evaluation. This study will evaluate one approach that will include primary care as the setting for ACP.Methods/design: This study will help to determine the feasibility for a definitive randomised trial to evaluate the implementation and outcomes of an ACP intervention. The intervention will be delivered by specially trained registered nurses in a primary care setting with older adults identified as at risk of functional decline. The intervention will comprise: (a) information collection via patient assessment; (b) facilitated informed dialogue between the patient, family carer, general practitioner and other healthcare practitioners; and, (c) documentation of the agreed support plan and follow-up review dates. Through a structured consultation with patients and their family carers, the nurses will complete a mutually agreed personalised support plan.Discussion: This study will determine the feasibility for a full trial protocol to evaluate the implementation and outcomes of an (ACP) intervention in primary care to assist older adults aged 70 years of age or older and assessed as being at risk of functional decline. The study will be implemented in two jurisdictions on the island of Ireland which employ different health systems but which face similar health challenges. This study will allow us to examine important issues, such as the impact of two different healthcare systems on the health of older people and the influence of different legislative interpretations on undertaking cross jurisdictional research in Ireland.Protocol Version: Version 1, 17 September 2019.Trial Registration: Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019. [ABSTRACT FROM AUTHOR]

Background: A well-functioning general practice sector that has a strong research component is recognised as a key foundation of any modern health system. General practitioners (GPs) are more likely to collaborate in research if they are part of an established research network. The primary aims of this study are to describe Ireland's newest general practice-based research network and to analyse the perspectives of the network's members on research engagement. Method: A survey was sent to all GPs participating in the network in order to document practice characteristics so that this research network's profile could be compared to other national profiles of Irish general practice. In depth interviews were then conducted and analysed thematically to explore the experiences and views of a selection of these GPs on research engagement. Results: All 134 GPs responded to the survey. Practices have similar characteristics to the national profile in terms of location, size, computerisation, type of premises and out of hours arrangements. Twenty-two GPs were interviewed and the resulting data was categorised into subthemes and four related overarching themes: GPs described catalysts for research in their practices, the need for coherence in how research is understood in this context, systems failures, whereby the current health system design is prohibitive of GP participation and aspirations for a better future. Conclusion: This study has demonstrated that the research network under examination is representative of current trends in Irish general practice. It has elucidated a better understanding of factors that need to be addressed in order to encourage more GPs to engage in the research process. [ABSTRACT FROM AUTHOR]

Background: The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call, regardless of acuity, to an emergency department (ED). A proposal to introduce Treat and Referral, an established care pathway in some jurisdictions, is under active consideration in Ireland. This will present a significant change. Stakeholder engagement is recognised as an essential component of management of such change. This study has conducted a multicentre, cross-sectional survey exploring opinions on the introduction of Treat and Referral among key Irish stakeholders; consultants in emergency medicine, paramedics and advanced paramedics.Methods: Public-sector consultants in emergency medicine (EM), registered paramedics and advanced paramedics, in Ireland at the time of the study, were invited to complete an on-line survey.Results: A significant finding was that 90% of both cohorts (EM consultants and registered paramedic practitioners) support written after-care instructions being given to referred patients, that > 83% agree that Treat and Referral will reduce unnecessary ambulance journeys and that 70% are in favour of their own family member being offered Treat and Referral. Consensus was reached between respondents that Treat and Referral would improve care and increase clinical judgement of practitioners. Differences were identified in relation to the increased availability of ambulances locally, that only adults should be included, and that research was required to extend Treat and Referral beyond the index conditions. There was no consensus on whether general practitioners (GPs) should be directly informed.Conclusions: This study identified that the Irish healthcare practitioners surveyed are supportive of the introduction of Treat and Referral into Ireland. It also affords healthcare policymakers the opportunity to address the concerns raised, in particular the clinical level which will be targeted for inclusion in this extended scope of practice. [ABSTRACT FROM AUTHOR]

Background: General practitioners report difficulty in knowing how to improve patient safety.Objectives: To analyse general practitioners' perspectives of contributing factors to patient safety incidents by collecting accounts of incidents, identifying the contributory factors to these incidents, assessing the impact and likelihood of occurrence of these incidents and examining whether certain categories of contributory factors were associated with the occurrence of high-risk incidents.Methods: Critical incident technique interviews were carried out with 30 general practitioners in Ireland about a patient safety incident they had experienced. The Yorkshire Contributory Factors Framework was used to classify the contributory factors to incidents. Seven subject matter experts rated the impact and likelihood of occurrence of each incident.Results: A total of 26 interviews were analysed. Almost two-thirds of the patient safety incidents were rated as having a major-to-extreme impact on the patient, and over a third were judged as having at least a bimonthly likelihood of occurrence. The most commonly described active failures were 'Medication Error' (34.6%) and 'Diagnostic Error' (30.8%). 'Situational Domain' was identified as a contributory domain in all patient safety incidents. 'Communication' breakdown at both practice and other healthcare-provider interfaces (69.2%) was also a commonly cited contributory factor. There were no significant differences in the levels of risk associated with the contributory factors.Conclusions: Critical incident technique interviews support the identification of contributory factors to patient safety incidents. There is a need to explore the use of the resulting data for quality and safety improvement in general practice. [ABSTRACT FROM AUTHOR]

Background: In the general practice setting screening, brief intervention and counselling have been shown to be effective in the reduction of problem alcohol use. This study aimed to explore Irish general practitioners' (GPs) current practice of and attitudes towards the management of problem alcohol use. Methods: An online survey was emailed, with one email reminder, to 1750 general/family practitioners who were members of the Irish College of General Practitioners (ICGP) and for whom an active email address was available. Overall, 476 completed questionnaires were received representing a 27.2% response rate. Results: Two-thirds of the respondents reported that they have managed patients for problem alcohol use and related issues in the past year. The majority, 96%, of respondents indicated that they initiate conversations around alcohol even when the patient does not do so. Almost two thirds of GPs stated that they use structured brief intervention when talking to patients about their alcohol intake and circa 85% reported that they provide some form of counselling in relation to reducing alcohol consumption. While more than two out of three GPs felt prepared when counselling patients in relation to alcohol consumption, almost half considered they are ineffective in helping patients to reduce alcohol consumption. One third of GPs advised that they did not have access to an addiction counsellor. Conclusions: GPs in this survey reported widespread experience of screening and intervention, however, many still felt ineffective. In order to maximise the potential impact of GPs, a clearer understanding is required of what interventions are effective in different scenarios. Furthermore, GPs are only part of the solution in terms of addressing alcohol consumption. The services available in the broader health care system and Government alcohol related policy needs to further support GPs and patients. [ABSTRACT FROM AUTHOR]

Background: Medication errors frequently occur as patients transition between hospital and the community, and may result in patient harm. Novel methods are required to address this issue.Aim: To assess the feasibility of introducing an electronic patient-held active record of medication status device (PHARMS) at the primary-secondary care interface at the time of hospital discharge.Design and Setting: A mixed-methods study (non-randomised controlled intervention, and a process evaluation of qualitative interviews and non-participant observation) among patients >60 years in an urban hospital and general practices in Cork, Ireland.Method: The number and clinical significance of errors were compared between discharge prescriptions of the intervention (issued with a PHARMS device) and control (usual care, handwritten discharge prescription) groups. Semi-structured interviews were conducted with patients, junior doctors, GPs, and IT professionals, in addition to direct observation of the implementation process.Results: In all, 102 patients were included in the final analysis (intervention n = 41, control n = 61). Total error number was lower in the intervention group (median 1, interquartile range [IQR] 0-3) than in the control group (median 8, IQR (4-13.5, P<0.001), with the clinical significance score in the intervention group also being lower than the control group (median 2, IQR 0-4 versus median 11, IQR 5-20, P<0.001). The PHARMS device was found to be technically implementable using existing information technology infrastructure, and acceptable to all key stakeholders.Conclusion: The results suggest that using PHARMS devices within existing systems in general practice and hospitals is feasible and acceptable to both patients and doctors, and may reduce medication error. [ABSTRACT FROM AUTHOR]

Abstract: Medications use in adults ageing with Down syndrome (DS) has not been studied extensively. People with DS are at increased risk of hypothyroidism, seizures, and dementia. It is possible that this pattern of multimorbidity is associated with polypharmacy. The aim of this study is to describe the patterns of medical disorders, symptoms, and medications, variation with age and residential setting, and utilization of health screening in an ageing cohort with DS. Data were obtained from wave one (2009/2010) of the Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing. Information on disorders, symptoms, health screening, and medications was gathered using preinterview questionnaires and face to face interviews with participants and/or caregivers. Of the 721 participants answering the questions about medication use and cause of intellectual disability, 20% had DS (n = 144). Descriptive statistics describe the prevalence of disorders and medications and proportion of participants attending health screening for disorders commonly associated with DS. The most commonly reported disorders were eye disease (61.8%), thyroid dysfunction (38.2%), constipation (34.7%) high cholesterol (32.6%), pain (32.1%), and emotional/psychiatric/nervous disorder (25%). The most commonly reported medications were thyroid hormones (43.8%), laxatives (27.1%), pain relievers (27.1%), and lipid modifying agents (26.4%). Polypharmacy, excessive polypharmacy, and multimorbidity were more prevalent among the older group compared to the younger group (37.3% vs. 14.3%; 13.4% vs. 7.8%; 73.1% vs. 58.4%, respectively). Uptake of memory assessments (32.9%), hearing tests (23.8%), and bone density screening (9.2%) was poor, particularly among those living independently, yet general practitioner visits were frequent and extensive. Polypharmacy and excessive polypharmacy are prevalent in this population, yet the provision of health care screening is inadequate. Medications review is needed since the risks posed by multiple medications use have not yet been quantified. As people with DS age, support is necessary for health care professionals, people with DS and their carers to help them optimize the use of medications. [ABSTRACT FROM AUTHOR]

Background: Primary care test requests for serum immunoglobulins are rising rapidly, with concerns that many requests may be unnecessary. Evidence suggests some characteristics of general practitioners (GPs) and practices are associated with higher test ordering.Objective: To identify the physician and practice characteristics associated with immunoglobulin test ordering.Methods: Retrospective, cross-sectional study using routine laboratory data on primary care serum immunoglobulin requests. Data were linked with GP patient list size data. The primary outcome measure was the count of test requests per GP. Predictor variables were physician gender, years experience, practice region and type (number of GPs), GP patient list size and composition. Mixed-effects multilevel regression models were used to calculate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for the associations between physician and practice characteristics and GP requesting. Sensitivity analysis was performed by limiting the model to the more than 70 years age category.Results: In total, 5990 immunoglobulin tests were ordered by 481 GPs in the South of Ireland during 2013. The number of tests ordered by individual GPs varied from one to 377. In the final fully adjusted Poisson regression analysis, female gender (IRR: 1.81; 95% CI: 1.45-2.26) and less experience (IRR: 2.27; 95% CI: 1.47-3.51) were associated with higher requesting (P < 0.001). None of the practice factors were associated with test ordering. Sensitivity analysis on the 70 years or more age category found similar results.Conclusion: Further research is required to explore the potential reasons for higher requesting among GPs with fewer years of experience and also among female GPs. [ABSTRACT FROM AUTHOR]

Primary care psychology services ( PCPS) represent an important resource in meeting the various health needs of our communities. This study evaluated the PCPS in a two-county area within the Republic of Ireland. The objectives were to (i) examine the viewpoints of the service for both psychologists and stakeholders (healthcare professionals only) and (ii) examine the enactment of the stepped care model of service provision. Separate surveys were sent to primary care psychologists ( n = 8), general practitioners ( GPs; n = 69) and other stakeholders in the two counties. GPs and stakeholders were required to rate the current PCPS. The GP survey specifically examined referrals to the PCPS and service configuration, while the stakeholder survey also requested suggestions for future service provision. Psychologists were required to provide information regarding their workload, time spent on certain tasks and productivity ideas. Referral numbers, waiting lists and waiting times were also obtained. All 8 psychologists, 23 GPs (33% response rate) and 37 stakeholders (unknown response rate) responded. GPs and stakeholders reported access to the PCPS as a primary concern, with waiting times of up to 80 weeks in some areas. Service provision to children and adults was uneven between counties. A stepped care model of service provision was not observed. Access can be improved by further implementation of a stepped care service, developing a high-throughput service for adults (based on a stepped care model), and employing a single waiting list for each county to ensure equal access. [ABSTRACT FROM AUTHOR]

Background: Economic evaluation of palliative care has been slow to develop and the evidence base remains small. Aim: This article estimates formal and informal care costs in the last year of life for a sample of patients who received specialist palliative care in three different areas in Ireland. Design: Formal care costs are calculated for community, specialist palliative care, acute hospital and other services. Where possible, a bottom-up approach is used, multiplying service utilisation by unit cost. Informal care is valued at the replacement cost of care. Setting/participants: Data on utilisation were collected during 215 'after death' telephone interviews with a person centrally involved in the care in the last year of life of decedents who received specialist palliative care in three areas in Ireland with varying levels of specialist palliative care. Results: Mean total formal and informal costs in the last year of life do not vary significantly across the three areas. The components of formal costs, however, do vary across areas, particularly for hospital and specialist palliative care in the last 3 months of life. Conclusion: Costs in the last year of life for patients in receipt of specialist palliative care are considerable. Where inpatient hospice care is available, there are potential savings in hospital costs to offset specialist palliative care inpatient costs. Informal care accounts for a high proportion of costs during the last year of life in each area, underlining the important role of informal caregivers in palliative care. [ABSTRACT FROM AUTHOR]

Background: Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Methods: Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. Results: There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by GPs but not by nurses or clinical therapists. Conclusion: PCPs and GPs agree there is limited PCT implementation. GPs are most negative about this implementation. There is some disagreement about which resources are most important for effective PCT working. These findings provide valuable data for clinicians and policy makers about implementation of interdisciplinary teams in primary care. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to collect and analyse examples of poor teamwork between junior doctors and nurses; identify the teamwork failures contributing to poor team function; and ascertain if particular teamwork failures are associated with higher levels of risk to patients.Design: Critical Incident Technique interviews were carried out with junior doctors and nurses.Setting: Two teaching hospitals in the Republic of Ireland.Participants: Junior doctors (n = 28) and nurses (n = 8) provided descriptions of scenarios of poor teamwork. The interviews were coded against a theoretical framework of healthcare team function by three psychologists and were also rated for risk to patients by four doctors and three nurses.Results: A total of 33 of the scenarios met the inclusion criteria for analysis. A total of 63.6% (21/33) of the scenarios were attributed to 'poor quality of collaboration', 42.4% (14/33) to 'poor leadership' and 48.5% (16/33) to a 'lack of coordination'. A total of 16 scenarios were classified as high risk and 17 scenarios were classified as medium risk. Significantly more of the high-risk scenarios were associated with a 'lack of a shared mental model' (62.5%, 10/16) and 'poor communication' (50.0%, 8/16) than the medium-risk scenarios (17.6%, 3/17 and 11.8%, 2/17, respectively).Conclusion: Poor teamwork between junior doctors and nurses is common and places patients at considerable risk. Addressing this problem requires a well-designed complex intervention to develop the team skills of doctors and nurses and foster a clinical environment in which teamwork is supported. [ABSTRACT FROM AUTHOR]

Objective:To investigate changes in attitudes, resources, and practices of general practitioners (GPs) toward evaluating medical fitness to drive (MFTD) following the publication of national guidelines and an extensive educational programme in traffic medicine. Method:Postal questionnaire survey to GPs (n =1,000) in November 2013. Results:The final response rate was 46%. GPs are confident (57%) or very confident (14%) in assessing MFTD. There is a high awareness of the new Irish guidelines, with 86% of GPs using them for assistance in assessing MFTD. GPs are divided as to whether GPs (49%) or practitioners specially trained to assess MFTD (44%) should be primarily responsible for assessing MFTD. GPs expressed interest in traffic medicine educational programs, most notably a resource pack for continuous medical education (CME) Small Group learning (87%), MFTD software (71%), and an online moodle (68%). Many (68%) remain concerned about their liability in regard to MFTD assessments. Conclusion:Irish GPs are confident in assessing MFTD and show a high level of awareness of the new guidelines. There is a clear interest among GPs in further educational supports and training in traffic medicine, particularly MFTD assessments. [ABSTRACT FROM AUTHOR]

Objective The study sought to assess opinions and attitudes of general practitioners ( GPs) in Ireland towards fitness to drive ( FTD) assessment in people older than 65 years old as well as to gather information on current assessment practices. Method A postal-based cross-sectional survey was carried out with 603 GP practices randomly selected using the Irish College of General Practitioners database. Results Response rate was 42.6%. The prevalence of GPs not confident in assessing FTD was less than 15% with 81% reporting the need for more education on assessing FTD, and 82% identifying that mandatory reporting of unsafe drivers posed a conflict of interest. Only 37% of GPs always/often used the Irish Road Safety Authority handbook when assessing FTD with 14% not aware of its existence. Of responders, 89% were of the opinion that a clinical assessment tool would be of benefit in assessing FTD. Conclusion Our study highlights the need for education and training for Irish GPs on FTD assessment in the older people patient population. [ABSTRACT FROM AUTHOR]

Aim: Being physically active has many proven health benefits and promoting physical activity to patients in primary care is an important component of public health programmes. This study examined the knowledge and practices of general practitioners and physiotherapists in the promotion of physical activity in primary care. Subject and methods: A cross-sectional population survey was conducted in Ireland to establish participants' knowledge of physical activity guidelines and current practice in the promotion of physical activity. A total of 342 general practitioners (response rate 65 %; n = 543) and 89 physiotherapists (response rate 88 %; n = 101) responded to the survey. Results: More physiotherapists (50.5 %; n = 45) than general practitioners (28 %; n = 97) correctly reported the minimal physical activity guidelines ( X² = 16.56, p < .005, df = 1). General practitioners reported screening physical activity opportunistically (41 %; n = 139) and when related to a patient's presenting complaint (37 %; n = 126). Physiotherapists reported screening physical activity routinely (34 %; n = 30) and when related to the presenting complaint (28 %; n = 25). With the exception of overweight patients, general practitioners were more likely than physiotherapists to promote physical activity to patients with known cardiovascular risk factors such as hypertension ( X² = 49.65, p < .001, df = 2) and hypercholesterolemia ( X² = 32.58, p < .001, df = 2). Physiotherapists, however, were more likely to promote physical activity to healthy populations ( X² = 9.91; p < .01, df = 2). Education and advice was the intervention most frequently used (general practitioners 76 %; n = 258, physiotherapists 97 %; n = 86). Conclusion: Despite high levels of awareness of physical activity promotion amongst general practitioners and physiotherapists, there is scope to improve physical activity promotion particularly to healthy populations and ongoing challenges to incorporate evidence based interventions into routine care. [ABSTRACT FROM AUTHOR]

Objectives:To explore the attitudes of Irish and Swedish General Practitioners (GPs) to the diagnosis and disclosure of dementia to patients; to investigate GP under-graduate/post-graduate training in dementia; to examine the post-diagnostic support services available to GPs in both countries and to investigate the extent to which dementia is perceived as stigmatising. Methods:A cross-national exploratory qualitative design was used. In-depth interviews were conducted with five Irish and four Swedish GPs. Interviews were transcribed, translated, thematically coded and categorised. Results:Both Irish and Swedish GPs unequivocally considered the early diagnosis of dementia important but neither group was proactive in making a diagnosis. Both groups relied heavily on family members or patients to bring to their attention memory loss and cognitive impairment problems. Most GPs reported a reluctance to diagnose and several acknowledged going to considerable lengths to avoid using the word ‘dementia’. The Swedish GPs had more exposure to dementia-specific training, saw the value in training and were generally very satisfied with post-diagnostic dementia services available to patients, while Irish GPs were less likely to have undergone training, were more equivocal about its value and were very dissatisfied with the community services available. Conclusion:Despite the presence of very adequate post-diagnostic support services for people recently diagnosed with dementia, the majority of Swedish GPs like their Irish counterparts displayed therapeutic nihilism and were reluctant to speak overtly to their patients about their dementia. Dementia continues to be a stigmatising illness for both Irish and Swedish GPs. [ABSTRACT FROM PUBLISHER]

The aim of this study was to explore key stakeholders and direct care managers' perspectives on the current provision of end-of-life care for older people in acute and long-stay care settings in Ireland and to construct a model of these. Although the literature reveals a number of factors that impact on end-of-life care, no study has examined staff perceptions concerning the provision of good end-of-life care for older people in an Irish context. Grounded theory was used. Semi-structured interviews were employed to collect data between 2007-2008. A purposive sample of 33 staff involved in the delivery of end-of-life care to older people working in six sites were selected. Factors that influence provision of end-of-life care in Ireland were identified. The core category was 'dying well'. The potential to 'die well' was influenced by three factors, namely philosophy, culture and organisation of care, knowing the person and physical environment and resources. People are living longer consequently acute and long-stay care setting will increasingly become places where older people die. This study identified the factors that influence the provision of good end-of-life care for older people. Mobilising resources to ensure that these factors are considered is crucial to ensuring that regardless of where older people die in Ireland, they will receive the highest standard of care that nurses can provide. Understanding the factors that influence the provision of end-of-life care in acute and long-stay facilities in Ireland can help health professionals give more focused support and ensure that influencing factors are addressed so that older people at end-of-life receive quality end-of-life care. [ABSTRACT FROM AUTHOR]

Background: Estimating the supply of GPs into the future is important in forecasting shortages. The lengthy training process for medicine means that adjusting supply to meet demand in a timely fashion is problematic. This study uses Ireland as a case study to determine the future demand and supply of GPs and to assess the potential impact of several possible interventions to address future shortages. Methods: Demand was estimated by applying GP visit rates by age and sex to national population projections. Supply was modelled using a range of parameters derived from two national surveys of GPs. A stochastic modelling approach was adopted to determine the probable future supply of GPs. Four policy interventions were tested: increasing vocational training places; recruiting GPs from abroad; incentivising later retirement; increasing nurse substitution to enable practice nurses to deliver more services. Results: Relative to most other European countries, Ireland has few GPs per capita. Ireland has an ageing population and demand is estimated to increase by 19% by 2021. Without intervention, the supply of GPs will be 5.7% less than required in 2021. Increasing training places will enable supply to meet demand but only after 2019. Recruiting GPs from overseas will enable supply to meet demand continuously if the number recruited is approximately 0.8 per cent of the current workforce per annum. Later retirement has only a short-term impact. Nurse substitution can enable supply to meet demand but only if large numbers of practice nurses are recruited and allowed to deliver a wide range of GP services. Conclusions: A significant shortfall in GP supply is predicted for Ireland unless recruitment is increased. The shortfall will have numerous knock-on effects including price increases, longer waiting lists and an increased burden on hospitals. Increasing training places will not provide an adequate response to future shortages. Foreign recruitment has ethical considerations but may provide a rapid and effective response. Increased nurse substitution appears to offer the best long-term prospects of addressing GP shortages and presents the opportunity to reshape general practice to meet the demands of the future. [ABSTRACT FROM AUTHOR]

Background: Primary care research networks have been established internationally since the 1960s to enable diverse practitioners to engage in and develop research and education and implement research evidence. The newly established Western Research and Education Network (WestREN) is one such network consisting of a collaboration between the Discipline of General Practice at NUI Galway and 71 West of Ireland general practices. In September 2009 all member practices were issued with a questionnaire with two objectives: to describe the structure and characteristics of the member practices and to compare the results to the national profile of Irish general practice. Methods: A postal survey was used followed by one written and one email reminder. Results: A response rate of 73% (52/71) was achieved after two reminders. Half of practices were in a rural location, one quarter located in an urban setting and another quarter in a mixed location. Ninety-four per cent of general practitioners practice from purpose-built or adapted premises with under 6% of practices being attached to the general practitioner's residence. Over 96% of general practitioners use appointment systems with 58% using appointment only. All practices surveyed were computerised, with 80% describing their practices as 'fully computerised'. Almost 60% of general practitioners are coding chronic diagnoses with 20% coding individual consultations. Twenty-five per cent of general practitioners were single-handed with the majority of practices having at least two general practitioners, and a mean number of general practitioners of 2.4. Ninety-two per cent of practices employed a practice nurse with 30% employing more than one nurse. Compared to the national profile, WestREN practices appear somewhat larger, and more likely to be purpose-built and in rural areas. National trends apparent between 1982 and 1992, such as increasing computerisation and practice nurse availability, appear to be continuing. Conclusions: WestREN is a new university-affiliated general practice research network in Ireland. Survey of its initial membership confirms WestREN practices to be broadly representative of the national profile and has provided us with valuable information on the current and changing structure of Irish general practice. [ABSTRACT FROM AUTHOR]

Background: Sexual problems are common among people with coronary heart disease and can adversely affect patients' quality of life. GPs are ideally placed to deal with these problems. Research suggests that GPs are reluctant to address sexual problems but little is known about what currently takes place in practice. The aim of this study was to examine GPs' self-reported behaviour and attitudes to discussing sexual problems with people with coronary heart disease. Method: Design: A cross-sectional survey which administered 230 postal questionnaires to a nationally representative, stratified random sample of GPs in the Republic of Ireland. GPs were asked about current practice, knowledge, awareness and confidence in dealing with sexual problems, barriers to addressing sexual problems, and about improving services in this area. Results: Responses were available for 61 GPs (27% response rate). Seventy percent of GPs reported that they rarely or never discussed sexual problems with coronary patients. While all GPs believed addressing sexual problems was important, many GPs reported lacking awareness, knowledge and confidence in addressing sexual problems. The main barriers were lack of time, feeling the patient wasn't ready and lack of training in the area. GPs wanted more training and guidelines for practice. Conclusions: There is currently no standardised protocol for GPs for dealing with sexual problems among coronary patients. Awareness of these issues appears to be low among GPs. Services could be improved by developing practice guidelines for brief, effective actions or assessments, providing training in the area and improving information resources and support services for referral. [ABSTRACT FROM AUTHOR]